\J
^ \
[American Library or Dental Science.]
COMPLETE ELEMENTS
OF THE
SCIENCE AND ART
OP
THE DENTIST.
BY M D E S I R A B O D E ,/
SURGEON DENTIST TO THE KING,
ASSISTED BY HIS SONS, DOCTORS OF MEDICINE.
FOLLOWED BY
An Historical and Chronological Notice of the Works published on the Dental Art,
from the time of Hippocrates.
ADOPTED FOR THE SCHOOLS OP MEDICINE AND PHARMACY, BY MINISTERIAL ORDINANCE,
RENDERED UPON THE REPORT OP THE ROYAL CODNCIL OP PUBLIC INSTRUC-
TION ; AND POR THE HOSPITALS OP THE PORTS AND COLONIES OP
FRANCE, BY MINISTERIAL ORDINANCE, UPON THE RE-
PORT OF THE INSPECTOR GENERAL OP THE
MARINE SERVICE OP HEALTH.
SECOND EDITION
Translated from the French, for the American Library pf Denial Science.
BY * — A.
15-77^
BALTIMORE:
PUBLISHED BY THE AMERICAN SOCIETY OF DENTAL SURGEONS.
JOHN W. WOODS, PRINTER.
1847.
I
wu.
\2H7
Entered, according to the Act of Congress, in the year 1847, in the Clerk's
office of the District Court of Maryland.
INTRODUCTION.
Whatever may be the science to the study of which we de-
vote ourselves, we may promote our advancement and faciUtate
inquiry in two ways entirely different from each other.
The one consists in patiently re-examining whatever of doubt-
ful character certain points of the science in question may in-
volve, in submitting them to a new investigation, enlightened
by the knowledge of the first causes; then to deduce from them
general principles in harmony with the degree of advancement
to which the other parts of our knowledge have attained, that
have with them either simple analogies of origin or direct rela-
tions of the end.
The other consists in collecting all the facts that experience
has positively and definitely determined, in binding the two
together, and to establish upon their methodical resemblance
and their reciprocal connections, principles immediately appli-
cable to practice.
The first of these two modes, more elevated, perhaps more
worthy, constitutes that which we have concluded to call phi-
losophical study, from whence flows Theory. The other, more
modest, but not less useful, since it represents in the tree of
science the branch which bears the fruit, constitutes the study of
application, from which is derived art properly so called, or that
which we term Practice.
Medicine, whatever may be the fundamental homogenity of
the parts of which it is composed, and the firmness of the prin-
ciples which serve as a base for it, can no more than the other
sciences withdraw itself from this double mode of study and
this division in its exercise.
Thus, although theory and practice, far from excluding each
other, and progressing separately, ought, without doubt,more than
any other thing, reciprocally to enlighten each other, and lend,
IV INTRODUCTION.
under all circumstances, a mutual aid ; it is no less true than
strange, that among those who devote themselves to the allevia-
tion of human suffering, there are many who, adopting their theo-
ry, as it were, ready made, occupy themselves exclusively with
its application. Still more, in this already circumscribed sphere,
some confine themselves to a single branch, which they make
the object of an exclusive preference and the subject of a par-
ticular study.
Such are dentists, oculists, lithotomists accoucheurs, her-
nial surgeons, orthopedists ; all those, in a word, who devote
themselves to that which we commonly name a speciality.
Is this admission of the specialities in the practice of medi-
cine of any advantage in the progress of the art, and, therefore,
as profitable to mankind as the interested parties have generally
pretended, and have endeavored to make others believe.
Without wishing to examine thoroughly the value of these
assertions by which each specialitist seeks to justify his excep-
tionable position, and to make comparative advantages result
from it, we think nevertheless that, if it is permissible to reply
affirmatively to the question we have stated, it ought certainly
to be so for dental medicine and surgery; not certainly supe-
rior by reason of the importance we would assign to the organs
which form its domain, for all the parts of the economy are to
our eyes important, since they are essentially necessary for the
continuance of life and the preservation of health ; but be-
cause, if it is demonstrated by daily experience that all the op-
erations which belong to the other specialities are executed with
an undoubted superiority by surgeons who occupy themselves
with the general art, it is evident that dental surgery not only de-
mands the various and complete studies which are indispensa-
ble to the practice of the other branches of medicine, but it has
still more, a very distinct and imperious necessity of a know-
ledge of all the particulars of mechanism.
Now, this knowledge acquired only by those studies which
application in no other part of their practice find, would draw
away by far too much those who destine themselves to general
medicine, and even simply to surgery.
Thus have there been, from time immemorial, some who oc-
INTRODUCTION.
cupied themselves exclusively with the diseases of the mouth,
the treatment of which they specially require, and even the
care very frequently necessary for the restoration of the dif-
ferent parts which compose it, but particularly the teeth. The
writings of Herodotus and Hippocrates, among the Greeks ; of
Celsus, Pliny, Martial and Horace, among the Romans, have not
left, as we shall more than once be able to prove, any doubt upon
this subject.
Unfortunately at this remote epoch, and even at a more re-
cent period, dental surgery being included in that unjust dis-
dain Avith which the most absurd of prejudices had stigmatised
manual medicine, properly so called, was the prey of empirics, of
charlatans, and even of jugglers, ignorant men, who, following
the judicious remark of Theodore Zwinger, had no reputation
to risk, no merit to expose, and above all, he might have been able
to add, no security to offer : who would have extracted with impu-
nity a tooth and inflicted at the same time, upon the mouth, every
possible mutilation. Besides, their ignorance found its excuse
in the opinion so generally spread, and which their irrational
manoeuvres constantly maintained, that the extraction of a tooth
could not be effected without mangling the gums or at least
breaking the alveolus !
It was reserved for the present age, besides being so fruitful
in useful information and salutary institutions, to do away with
an abuse so contrary to the dignity of the art, so little conforma-
ble to the good of mankind, and against which there were in-
effectually exerted, with all the strength of their genius and the
influence of their position, the efforts-of Ambrose Pare, Guy de
Chauliac, Vigo, Dionis, who were at that time the fathers and
glory of French surgery.
The lawof the 5th of March, 1802, in refusing to any one the
right of exercising the art of healing, without having obtained,
by public examination, the grade of doctor of medicine or the
title of oflicer of health, has implicitly recognised, in spite of
the decree of the supreme court of the 23d of February, 1827,
(a decree which constitutes an omission without establishing a
principle,) this law we say, has declared, that the preservation
of organs so valuable as the teeth ought not to be abandoned
VI INTRODUCTION.
to the Stupid and brutal ignorance of empirics, whose destruc-
tive vandahsm might constantly be attended with the most se-
rious errors, and, consequently, the most deplorable accidents.
"One of the most distinguished surgeons of our day, M. Mar-
jolin,* whose word will always be authority when he speaks of
that which relates to the good of the science and the dignity of
the profession, truly says, the exercise of the art of the dentist
constantly demands knowledge greatly extended and compli-
cated. Hence it is important it should be practiced by those
who have made it the exclusive object of their studies; for den-
tistry does not consist in a knowledge of the most evident af-
fections of a tooth, and the performance on it of the most simple
operations and the most clumsy manipulations ; it is necessary to
have the most accurate knowledge of the anatomy of the mouth,
particularly that of the teeth, and to unite general notions of
anatomy, physiology, medicine, hygiene, mechanism, and still
more, the skill of the goldsmith."
In publishing a new treatise upon the Art of Dentistry, an art
which no word expresses directly in our language, but which
we cq\\ odontology , or odontechny ^ when it is confined to the
study of the teeth, and stomatonomy^ when it comprehends all
the parts which compose the mouth, we have not the proud
pretension either of rebuilding this branch of medical science
upon a new basis, or of placing ourselves above our professional
brethren.
On the contrary, we are anxious to acknowledge to all, not
only that this basis has been laid in a solid manner, by Fauch-
ard, more than a century ago, whom Ave regard with reason as
the restorer, or to speak more plainly, as the father of dental sur-
gery,! but we recognise still more the developments that are
given to the principles laid down by this celebrated practitioner,
» Nouveau Dictionnaire de Medicine, article Dent,
t It is by order of merit, and not of date, that we place Fauchard at the
head of authors who have written upon dental medicine ; it is true, the first
edition of the work of this illustrious practitioner was not published until
1728, and as far back as 1582, it is said, nearly a hundred and fifty years
before, Urbain Hemard had published ra Lyons, an Essay upon the art of
the dentist, in which some very judicious precepts were found united in the
form of doctrine.
INTRODUCTION. Vll
by the works of Lecluse,Bourdet, Jourdain,Gariot, and more re-
cently those of M. M. Duval, Delabarre, Laforgue and even Le-
maire, forming, by their combination, a theory which has permit-
ted this art to march side by side with the other parts of our
knowledge, whose study has for its means and end, the cure of
the diseases of man.
But our principle motive in writing, has been to unite in the
same treatise all that which medical science, in its different
branches possesses more immediately applicable to our speciali-
ty, and to make subservient to the establishing of many practi-
cal facts too lightly admitted, and even, it is necessary to say it,
to the reforming of many errors, an experience acquired un-
der circumstances the most favorable, an experience the extent
of which we think no one can, at least without injustice, doubt,
so far as the art properly so called is concerned.
For, it is not necessary to conceal the fact, that we are evi-
dently at an age, in which the progress of reason and light,
urges the world to free itself from the great evils which induce
disease of the teeth, and to conceal the ravages which acci-
dent, in spite of every precaution, is liable, at every age, to inflict
upon the mouth, forcing the dentist to make the operative and
mechanical part of his art, if not his exclusive business, at least,
his principal element.
Undoubted truth, by which our professional brethren have
daily profitted and regulated their conduct, though very few
have had the courage, not to say the sincerity of avowing it pub-
licly. As if our calling, when it may be reduced to the propor-
tions of a mathematical art, even purely mechanical, could not
now, by the great services which it renders in this isolated
branch, be worthy of the most profound study, and throw some
brilliancy upon the career of him, who devotes himself unre-
servedly to it, without the fear of passing for a limited practitioner,
and of being confounded with quacks.
In reducing to its true state, all that which properly belongs to
this work, we, doubtless, may omit reproducing by the publi-
cation of a complete treatise upon the subject, opinions which
have been before expressed, and which have become, for this
very reason, the elements of our art. But as there are few
VIU INTRODUCTION.
points, in practice especially, that our experience has not de-
monstrated susceptible, if not of a total reformation, at least, a crit-
ical examination, of which, the result may be a modification of
the operator's procedure, we should have had difficulty in clas-
sifying our remarks, which, being offered separately, would
assuredly have lost their importance ; which, on the contra-
ry, being methodically interlaced in a complete work, form a
compendium -expressing exactly the true state of this part of the
science, able to serve as a guide for such, to persons who wish
to have a precise knowledge of it, and to make it a complete
manual.
There will no doubt be objections made to our work, because
there exists already many didactic works upon our art, speaking
only of those which have appeared in our day. It is true, and,
we are far from being ignorant of the fact, as we shall prove
sufficiently, and perhaps superabundantly for the good of some,
in the course of our treatise ; but of these works, generally, only
reproductions, commenting, more or less, upon each of those
which have preceded them ; what then are those which can be
called complete works ?
Are they those of M. Duval? Without sharing, in any man-
ner, the unjust disdain with which Laforgue treats the pro-
ductions of this respected teacher, we cannot refrain from avow-
ing that if these productions bear plainly the impress of the eru-
dite, even of the great man, it is the truth, they do not always
indicate the marks of a practitioner ; and that the most of the
excellent precepts they contain are buried under a load of quota-
tions, and figures Uttle calculated to produce that for which they
are essentially useful.
' Shall we search in the treatise of J. Lemaire on the teeth for
that which we are not able to find in the productions of M. Du-
val? No, assuredly ; for that work, though correctly written,
contains nothing that can guide the student destining him-
self to practice, and wishing, consequently, to see in a trea-
tise upon the teeth, something besides a display of rhetoric. It
is by an opposite fault, the works of Laforgue err, which con-
sist of only a dry assemblage of practical facts, which, although
often detached from the result of critical observation, are not
INTRODUCTION. IX
bound together by any doctrine, and seem rather dictated by a
desire to undervalue than to instruct.
Let the works of M. Delabarre, and those of Maury, now oc-
cupy our attention. But the first, ahhough they declare the
man instructed, and the practitioner as sincerely the friend of
his art, as impressed with the dignity of his profession, form not
by their union a complete treatise, since they treat of only cer-
tain isolated points ; and, we say it with regret, and the love of
truth demands from us this avowal, the most important of these
works, that one which bears the marks of most originality, his
7necha}iical denlistrt/, oSers, to whoever would study it thorough-
ly, the astonishing contrast of a brilliant theory, and of a prac-
tice sometimes so irrational, that it would seem to have been dic-
tated by the blindest empiricism. Thus, by the side of a truly
elevated scientific appreciation of the reactors (commonly desig-
nated by the name of resorts) we find a description given in the
most serious tone of an operation, the object of which, is the at-
tachment of a part of a set of teeth to the upper jaw, b7/ means
of what ? — of a band passing across the thickness of the max-
illary bone, 6^c. 6^c. ! ! *
As to the work of Maury, written under the influence of that
prejudice, which seemed a long time since to confine the dentist
within the narrow circle of the part essentially practical of his
speciality, everything therein is reduced to the proportions which
are rendered useful, only for an altogether summary study of the
matter, or to serve as a m,emento to those who know it already.
What we have said of the work of Maury, applies with still
more reason, to M. Lefoulon's work, which is little more than
a repetition, without the precision of certain practical details; it
has still more a certain wordy air, which betrays its true desti-
nation, and demonstrates that the instruction of dentists was not
the chief aim of the author, as we shall often have occasion to
prove, and as the practitioner himself proves, who thought hini-
• The term reactors applies more particularly to springs, such as are usu-
ally employed for retaining in the mouth a double set of artificial teeth; upper
dentures were also formerly confined in the uiouth by this means. — Trans-
lator.
2
INTRODUCTION.
self able to say in thirty-six lines, all that which concerns crotch-
ets, are better and the most habitual means of maintaining per-
manently in the mouth, the various parts of artificial teeth, and
who dievoiQs four pages to celebrating the virtues of the most in-
nocent odontolgic paste, which has always been extolled.
Being convinced that honesty is the first obligation, that those
who write, contract with society, we shall bring in this exposi-
tion, of that which is properly ours, nothing of that reserve and
discretion which some of our confreres exhibit in order to make
their discoveries, and operatory proceeding, mysterious. They
are ignorant how much they render themselves culpable by it ;
for, if these proceedings are perfect, they injure the propagation
of them; if they are only superior to those which are generally
used, fortified by others, they might receive useful additions,
and, in every instance, render the most eminent services to the
public ; finally, if they are defective, they are liable, in refusing
to allow them to be seen, to turn incessantly in a vicious circle,
and often to fall from a position acquired by long and difficult
labors.
If the love of science and the desire of general good are not,
to the eyes of our professional brethren improperly discreet, suf-
ficient motives to render public the discoveries to which they
have been conducted, sometimes by chance, sometimes by a par-
ticular position, let them remember that their personal interest,
for want of a more noble motive, demands it of them; and if
they are blinded by egotism to doubt this fact, let them medi-
tate upon the following words of a master of the art, whose tes-
timony and authority they often invoke. *
"That one Avho publishes a discovery, ought not to fear that
this publication will injure his interests; wealthy men always
address themselves to the inventors of useful discoveries be-
cause they think justly that the author of a process is commonly
the one who knows how to employ it best. Mystery on the
other hand, in a useful thing, always restricts 'its use ; it hin-
ders it from being spread, accredited, and always causes more in-
jury to the invention, than it procures advantages to him. I
* Gariot: Treatise upon the Diseases of the Mouth.
INTRODTTCTTON. Xi
think, then, that it is always by a false calculation, that one keeps
a secret of this nature ; for, in admitting that the inventor of a
discovery, experiences some injury in divulging it, this injury
could not assuredly be put in the balance with the satisfaction
that he ought to experience by its general use."
To employ method in our work, and to bind all the parts
which compose it in such a manner, that practical principles
shall flow naturally from physiological facts ; that each object
shall present itself in its turn, that is to say, following its rela-
tive importance, that art, in a word, shall only be the summary of
science, we have divided this work in two parts, forming two
volumes, susceptible, nevertheless, of being united in one.
The first contains four chapters, forming four principal divi-
sions, the first is devoted to anatomy^ the second to physiology,
the third to hygiene and to orthopedia, the fourth to pathology
and to therapeutics : this is science. The second part compre-
hends, in two very distinct chapters, first, operative medicine ;
second, prosthesis, often so designated under the name of mechan-
ical dentistry ; this is art, in its most absolute sense.
This plan seems to leave little to be desired by us ; for, if by this
simple, methodical, and in fine, logical division that it gives, noth-
ing could have been omitted. In eifect, if it is evident that the
description of an organ, of whatever partof the body it ought to
proceed as an indispensable base, all dissertation upon it, is as
clear as its importance requires ; after the organ itself, are the
laws of its development, the functions which belong to it, and
the conditions upon which the integrity and entire accomplish-
ment of those rest. Hence anatomy, physiology, hygiene and
orthopedia.
When the preservation of hygiene becomes impossible, disease
manifests itself; \\enze, pathology, and necesszxS^Y therapeutics,
in which we include all which belongs to causes, as well distant
and predisposing as near and efficient to the particular character
of the diseases of the teeth and even of their principal connec-
tions, and to the treatment either medical, or surgical, which is
appropriated to these affections, operative medicine places itself
directly after pathology and therapeutics, of which it is one of
the means ; for in dental medicine, it forms one of the most pow-
XU INTRODUCTION.
erfiil resources, one of the agents to which we are unfortunately
most frequently compelled to have recourse. Finally, when art,
often unable to preserve, is forced to destroy, and when nature
has experienced the ravages of time, in the order it has imposed
upon itself, or has not been able to struggle against the innume-
rable causes of destruction which, at every age, menace inces-
santly the teeth, prosthesis is able, by the innumerable and mar-
vellous resources which it places within our reach, to furnish the
means of supplying all the losses that they often experience, so
as not only to deceive completely, but even of rendering detec-
tion impossible by the most experienced eye — thus :
rist. Anatomy;
Part First, J 2d. Physiology ;
Vol. I. i 3d. Hygiene and Orthopedia ;
(_4th. Pathology and Therapeutics.
Part Second, C 1st. Operative Medicine ;
Vol. 2. ( 2d. Prosthesis, or Mechanical Dentistry.
In adopting this plan, we are then, as every one sees, almost
sure, at least, of avoiding those two shoals, into which the most
of our predecessors have fallen, of committing incessant repeti-
tions, under the pretext of avoiding omissions, and of treating in
the same chapter,ofthose things essentially different, as of opiates,
powders, and even of teeth brushes, in the development of the
materials of dental prosthesis, and of means sometimes very tri-
fling, which insure the regularity of second dentition, through the
instrumentahty of manual medicine. Do not all these things
belong more directly to hygiene? since they have no other end
than to direct the execution of a function and prevent anything
from disturbing it, and placing it in a natural condition.
As to the secondary divisions established under the form of
paragraphs, every one accustomed to judge a work, will perceive
without difficulty, that in adopting those which we have follow-
ed, we have constantly had in view, to speak rather to the mind,
than memory, by our lectures ; in a word, to make true dentists
simple mechanics. In studying in effect each object, we have
considered it less following in the order in which it is employed
than in behalf of the principle which ought to serve as a guide
for its completion or adjustment.
INTRODUCTION, XIU
Thus, to quote an example taken from prosthesis, the most of
authors have made only a single article upon the pivoting meth-
od of applying artificial teeth: prepared the tooth, furnished it
with its pivot, prepared the root intended to receive it, and fixed
the tooth to it. The result is, that after having indicated the man-
ner of introducing and fixing the pivot in an artificial tooth, to be
placed upon a root, they are obliged to come back that they may
place it upon a metallic, osseous or mineral base.
We have, on the contrary, divided this operation into two
parts ; one which applies to the preparation of the tooth and fur-
nishing it with its pivot, the other treats of the implantation of the
pivot into the root. The first is described in the paragraph
which relates to the mounting of teeth upon their supports or
bases, the other in the paragraph specially appropriated to the
description of the different ways of maintaining pieces of artifi-
cial plate in the place which they ought to occupy in the mouth.
Being convinced that the materials which ought to compose a
complete treatise upon dental medicine and surgery, although
regarded only in a practical point of view, are, by themselves, so
extended, as to form the base of a voluminous and sufficiently im-
portant work to fix the sole attention of those persons who would
make it a thorough study ; we will carefully avoid the descrip-
tion of certain objects, which, as far as our art is concerned, be-
long to it no more than other professions, as well as anatomical
and pathological, which are the common property of medical sci-
ence.
Is it necessary to quote examples on this subject? Of what
use can it be in a work, addressed to dentists or to physicians
who wish to initiate themselves in the particulars of our art, to
make a minute description of convulsions, of pthyalism, and of
opthalmy, which sometimes accompany the eruption of teeth,
since these diseases are described with all detail and possible
exactness in the different general treatises of pathology, which
study should precede all special application. This description is
even fastiduously repeated in all the works devoted to the disease
of children.
For the same reason, with what advantage has Maury, who is
one of the last writers upon our art, thought to gain by following
XIV INTRODUCTION.
that part of his work, on operative medicine, by minute details
on the description of forges, the malleabihty of metals, and the
tempering of instruments which we shall use? These diifer-
ent things might, and even ought to be mentioned in their con-
nection with our wares, but not minutely described, for they be-
long no more to dental surgery, than to cutlery, or to the profes-
sion of the jeweller. He might as well have described the la-
bors of Montmartre, under the pretext that they furnished the
plaster, which we employ to obtain the representation of mechan-
ical pieces or of prosthesis, or that we are obliged to employ in
some irregularities of conformation that we wish to correct. Be-
sides, what could have appeared more inappropriate, to say noth-
ing more, than to devote twenty pages to the natural history of
platina and to washing of ashes, and an entire chapter, not only
to the treating of certain physical and moral qualities which the
dentist ought to possess, but still more to a minute description,
pardon us for the expression, of the apartment that he ought to
occupy, and of the furniture which should embellish it.
Is it for the sake of erudition that the author whom we have
quoted has adopted this course, filled with superfluities, in the
midst of which, the end is necessarily sacrificed to the form,
the indispensable to the accessory ? He would, according to our
opinion, been able to have attained his end better by giving an
exact account of the recent labors of Cuvier, of M. M. GeoflE"ry
Saint Hillary, Serres and Rousseau, and by putting that part of
his work devoted to pathology and therapeutics more upon a
level with the actual state of the science.
To say, in effect, in anatomy, that "the teeth are the hardest
bones in the human body," and in therapeutics, that, to calm
the convulsions which accompany the age of dentition, "they
should hold the child as much as possible in the open air, put
salt in its mouth and apply cold water to his body," on the' one
hand, it is to content ourselves with propagating the most com-
mon opmion, and on the other, it is, at least, to recommend the
remedies of old women, if it is not to advocate irrational doc-
trines of medicine.
As to ourselves, we will seek no more to shine by a vain dis-
play of erudition, a pleasure any one can procure now-a-days, as
INTRODUCTION. XV
every one knows, than to be remarked for a pretentious style.
However multiplied may seem our quotations, we have, in the
meantime, confined them to the degree necessary to prove that
we have read all the important publications upon our art ; and
when any one shall give himself the troubleof comparing them,
he will easily perceive, that we are not content with read-
ing, but that we have meditated upon each author. We shall
think ourselves sufficiently erudite, if we shall first omit nothing
useful; secondly, if we shall mention all the sources which we
have consulted ; and we will suppose ourselves sufficiently elo-
quent, if we are so clear as to be easily understood.
Again, to render profitable and accessible to all the world the
researches that we were compelled in obligation to make, we
have added to our second part, under the form of an historical no-
tice, a list of most of the authors who have written upon our
art, either in a direct, or purely accessory manner. The alpha-
betical order, employed by some authors in treating upon this
subject, appears to us to be completely insignificant to the one
who wishes, above all things, to form an opinion of the successive
progress of the art, since he is liable to quote, at the same time,
works separated by ages, and to place constantly the original
work near that which is only a copy of it, we have substituted
for it the chronological order. By this means, each work of any
importance presents itself to us in the order of its publication,
and we will have under our eyes a picture of the principal dif-
ferent phases through which all the knowledge which has con-
ducted to that which we know to-day has passed.
We will divide this history into three periods : the ancient,
which comprehends all that which has been published upon the
teeth from the time of Hippocrates to the sixteenth century ; the
middle includes all the writings of the sixteenth and seventeenth
century; lastly the modern, which comprehends all those of any
importance, which have been published principally in France, in
the eighteenth, and all which have appeared in the nineteenth
century. In the first of these three periods, we will add there-
searches of M. Duval, and those which Blandin has more re-
cently made, at the same time being careful to point out with
precision the titles of these quoted works, and indicating accu-
XVI INTRODUCTION.
rately the period in which the authors which formed this remote
period have Uved. With regard to the two other periods, wears
permitted to contribute the works of M. Dezeimeris, and the
public notices contained in some of the medical dictionaries, to-
gether with such as we have ourselves discovered, making in all
at least one hundred and fifty works more than Maury, who has
given the most complete notice.* Hence we will allow no op-
portunity of escaping by which we can contribute to each epoch
whatever it may be entitled to, and in the review which we are
about making, in the course of which we will endeavor to an-
alyse faithfully and to judge impartially, we will often be able
to demonstrate, by facts, that the disdain which some modern
authors show for the works of our predecessors is not always
disinterested. But the desire of being just towards some who
have preceded us in this undertaking, will never prevent us
from declaring the merits of past times, or of forgetting the great
progress of our art at the present day.
On the other hand, our criticism will neither be severe or
partial. Above all things we desire the good of the profession
and the triumph of truth, we attack doctrines, not men, and
when names are inscribed by our pen we do it not so much
through the desire of elevating ourselves, at the expense of our
professional brethren who have written, as it will be to place the
reader in a position for judging between their views and our
own. If some should occur oftener than others, it is that being
placed within the first rank, they make themselves authority,
and thereby liable to draw the student into their own errors.
Finally, if we refer continually to dentists who have no art
beyond the general principles of the science, we hesitate not to
prove that more than one author, having written elementary trea-
tises of surgery or of operative medicine, has committed errors in
that part of his work devoted to our speciality, nor having that
knowledge which long experience has been able to give for the
» Some persons might perhaps think that this historical part should be
placed here. Our reply to this is, the fear of turning the attention from the
true motives we had in writing ihis treaiise, prevented us from takino- this
course, which was the grand object of the introduction, we therefore prefer
assigning to it a separate article al tho end of the work.
INTRODUCTION. XVII
most part to us. Wishing them to respond to our title, which
declares not only the art, but still more the science, we have
followed, by a natural thread, the progress that each part of this
art has made in arriving to our means ; and, in the description of
these means, we are compelled as much to make known the pro-
ceedings of our professional brethren as our own, reserving for
demonstration the reason which have made us prefer ours to
theirs.
For the same reason, when we have established a principle,
we have nearly always furnished as a support to it undoubted
proofs, by facts found in our own experience and in that of au-
thors the most worthy of credit, very different in that from the
most of those who hitherto have written in our speciality, in
personifying themselves, and in revolving in the sometimes too
restricted circle of their knowledge.
Can any one now reproach us with having neglected to treat,
as they have done most of our predecessors, upon the different
parts which compose the face, nay, even the whole head, prin-
cipally the interior of the mouth, the pharynx, the velum of the
palate, the tongue, for example, the nerves, the veins and arteries
which nourish it ? We suppose not, for physicians and dentists
know the force of this expression ; there is not one of the latter
to whom daily experience has not proved that we are nearly
always consulted relative to diseases of the teeth.
Hence it is, that the study of these organs and the means of
curing their diseases or of supplying their loss should princi-
pally demand our attention ; and this is what we have endeav-
ored effectually to accomplish. To discover the truth and to
present it in the most clear terms has been our principal object?
to be useful is our only wish ; should we have attained this, we
shall be sufficiently recompensed for the mistakes that we may
have committed in endeavoring to give proof of our zeal, that a
mistaken rivalry might have taxed with rashness ; but do
WHAT IS RIGHT, HAPPEN WHAT WILL.
SCIENCE AND ART OF THE DENTIST.
PART FIRST.
ANATOMY, ORTHOPEDIA, PATHOLOGY AND THERAPEUTICS.
CHAPTER I.
ANATOMY OF THE TEETH.
Nature has subjected all animals to the obligations of a gene-
eral law : this is to seek in surrounding bodies for those ma-
terials which are calculated to repair the injuries they sustain
from the continual succession of the phenomena of life, and af-
ter making a proper choice of these materials, to submit them to
various preparations, of which the teeth generally speaking, con-
stitute the principal agents.
Hence the teeth, considered in this general point of view, be-
come mechanical instruments, situated at the entrance of the ali-
mentary canal, for the purpose of seizing and dividing the nutri-
tive substances, and frequently to act at the same time as a means
of attack and defence.*
Some anatomists have given to the word tooth a much more
extensive signification, and have applied it to horns, which
occupy the same place in certain animals, f as the beak of a
bird ; they have also made use of it to designate any calcareous
or horny substance, that is seen either at the entrance of the diges-
tive organs, or in the midst of these organs, the object of which
is to keep a good hold of prey or to masticate food.
* F. CuviER : Des Dents des Mamraiferes, considerces comme carac-
tere zoologique. 1821.
* Geoffry Saint Hillary : System Dentair des Mammifcres ef des
oiseaux. Paris, 1824.
20 ANATOMY, ORTHOPEDIA,
We do not deny the analogy— on the contrary : but as our
object in the present work is to treat solely of human teeth, we
have no desire to ascertain how far from truth authors have
wandered in undertaking to give an almost unlimited sense to
a term which moreover designates any organ having an edged
character ; we will confine ourselves to the definition we have
adopted with Cuvier, and which appears to express in a clear and
general 'manner the organs we intend to treat of in the course
of this work.
Teeth have been long considered as real bones ; but anato-
mists and dentists,* who have admitted this identity have de-
pended upon simple appearances which a more critical exami-
nation has demonstrated utterly incorrect. Already has Beclard
and many other modern authors with him, raised doubts in re-
gard to it, and endeavored to sustain their views by the different
characters that exist between these two organs ; and which are
now-a-day considered perfectly distinct. They differ thus :
1st. In respect to position : The teeth are naked and outward-
ly visible, whereas bones, and this character is one of the most
important, are enclosed in a periosteum.
2d. In an anatomical point of view : Teeth are formed by a
bulb, or large papilla, surrounded by a calcareous case, composed
of two substances, enamel and ivory. This calcareous case is
not visibly penetrated by vessels, and presents no apparent ves-
tige of cellular tissue.f In the long bones is found a medul-
lary substance which bears some resemblance to the papilla of
the teeth, but the flat bones are free from it.
3d. In respect to their development: In the teeth the forma-
tion of the hard or bony substance takes place from the circum-
ference to the centre ; whereas in the bones, this development
is made inversely, that is to say, from within outwardy. J They
afterwards present a renewal that constitutes a second dentition,
* "The teeth are the most durable and compact bones of the body." Mau-
ry; Maury d PArt du Deateisle, page 17.
t J. Cruvilhier : Anatomie descreptive. 1834.
X M. Flourens endeavors to establish that the bony particles are furnish-
ed by the periosteum; but this opinion, which is but the reproduction ofthat
of Duhamel, is far from being generally adopted ; it has moreover found
strong opponents.
PATHOLOGY AND THERAPEUTICS, 21
a phenomena unparalleled in the history of the development of
bones.
4th. In a physiological point of view : Teeth are not as bones,
levers to which the muscles are attached, the latter being the
principal agents of our movements.
5th. In respect to chemical composition : Teeth possess a
greater quantity of salt — and jelly does not penetrate the texture
of the enamel, as we shall see hereafter, when giving detailed
analyses of all the substances which enter into their composi-
tion.
Finally, the best evidence of the essential difterence between
the teeth and bones, a proof to which no physician or dentist
has ever paid any attention, is, that the teeth never contract any
real adhesion to the jaws : Now, it is well known how easily the
organs of identical nature are united by the simplest pathologi-
cal effort. Again, teeth known under the name of adherence, are
nothing but teeth with diverging roots, upon which the alveo-
lar partitions are engrafted in such a manner, that following out
its various windings one would be inclined to believe that they
were really soldered together. The most minute researches have
never enabled us to prove this affinity, so often discovered
amongst the teeth, particularly at their roots,* as we shall soon
illustrate by example.
From what has been said, it evidently follows that there is no
analogy between the teeth and bone, except that they resemble
each other in hardness and color. How then shall we rank
them ? in what system of the economy? We do not hesitate to
believe with Cruveilhier, whom we have just quoted, and who
has followed the opinion of Aristotle,! adopted by Gallien, and
afterwards reproduced by Urbain Hemard,| that they belong to
the epidermic system. Here are the reasons upon which we
found this opinion, so generally prevalent now-a-days.
1st. Examined in the scale of animals, they form an uninter-
rupted series, from those that resemble the horns and nails, to
those that present the most marked bony appearance.
* Let any dentist separate this supposed adherent from the teeth, and
he will be assured of the justice of this remark,
t Aristotle : Book 2, chap. 9, etc. on the Parts of^nwials
I Researches upon the l^tie Jlnatomy of the Teeth. 1582.
22 ANATOMY, ORTHOPEDFA.
2d. Their texture is lamellated like that of the nails and hair.
This texture is quite visible in certain animals ; amongst others
it is not so, but only on account of the accumulation of the cal
careous salts.
3d. Their manner of development is similar to that of horns,
nails and hair; like them, they are deprived of apparent nutri-
tive organs, are formed layer by layer, and are merely the pro-
duct of secretion. Thus Geoffry Saint Hillary,* as we have
already said, considers the beak of a bird, which is evidently a
horned production as connected with the dentary formation.
Nmnber and Position of the Teeth.
The number of teeth in young persons at the period of first
dentition is twenty, ten in the upper jaw, and as many in the
lower. In the adult, this number is thirty-two, sixteen in each
jaw. Man has, consequently, in the course of his life, fifty-two
teeth : twenty temporary ones, and thirty-two that are permanent.
The teeth, by their uninterrupted series, form two para-
bolical curves corresponding to those presented by the alveo-
lar arches which serve as their support. These two series or
ranges constitute what is called the arches of the teeth. They
are kept as if nailed together in the alveolar cavity, which are
exactly moulded upon their roots. At the time when teeth were
looked upon as real bones, this arrangement went under the de-
nomination of gomphosis.
This relation of contact of the teeth with the alveolar is, how-
ever, only mediate. They have an immediate relation with the
alveolar prolongation of the gum called likewise alveolo- dental
periosteum, which envelopes the root, and with the dental pulp
that fills their cavity in becoming an integral part of themselves.
These are the two true means of union, by the assistance of which
the teeth are mechanically fixed in their alveoli. The import-
ance of this means of union will be fully appreciated by bearing
in mind the loosening of teeth in persons afflicted with scurvy, and
the facility with which they separate and fall in the skeleton
Each range of teeth, we have already stated, presents a re-
gular and uninterrupted curve ; this arrangement is found
* One of the most philosophical works il.al has boeu published unon .K
subject. * ""^
PATHOLOGY AND THKRAPEUTICS. 23
only in the human race. In animals, teeth have an unequal
length, and the border of the arches of the teeth is frequently
irregular ; besides their teeth are not continuous, and leave be-
tween them considerable intervals.
Hence it is, that in no animal do we find the teeth arranged
with so much regularity and elegance as in man ; in children
they form a semi-circle, which gives them quite a beautiful ap-
pearance. In adults they form an ellipsis which increases the
facial angle, and gives to the countenance a more stern and
marked character.
The arches of the teeth offer to our observation two fronts and
two borders. Their anterior front is convex, their posterior
front concave ; their adherent border or alveolus regularly fes-
tooned; their border free, thin and sharp in front, increases gra-
dually on the side where it is thick and with pimples. These
arches are not equal amongst themselves : the above one repre-
sents a more extensive curve than the one below, so that, placed
upon the same line, they form an oval by themselves, the first
being the large extremity, and the second the small one, and by
approximating they meet each other exactly at the bottom of the
mouth, whereas in front, the superior dental arch encases or sur-
rounds the lower. Whoever will examine the arrangement of the
teeth upon the skeleton during the coming together of the jaws,
will find that the incisors below, slip behind those above, that
the external tubercles of the lower grinders slip inside of the
external tubercles of the upper ; it follows, hence, that the first
correspond with the gutter that separates in the upper grinders
the range of the external tubercles from that of the internal tuber-
cles, or in other words, all the upper teeth increase beyond the
direction of their antagonists.
The teeth of tlie upper jaw are in the general a little more volum-
inous than those of the lower jaw. In a word, we would remark
that no tooth corresponds exactly with that which bears
the same name in the other jaw, we can always perceive a cir-
cuit of more or less extent, whence results, not merely a simple
contact, but an exact fit.
Exterior Conformation of the Teeth.
If we consider the configuration of the teeth, we shall not
only find that they possess certain general characters which vary
24 ANATOMY, ORTHOPEDIA,
from all the other parts of the organism, but that they have,
moreover, particular characters, which distinguish them amongst
themselves. Let us then turn our attention to the first, without
making any apology for entering into minute details ; for if
these details do not always find a direct application in pathology,
they become at least of absolute necessity when we wish to reme-
dy, by imitation, the parts which have been damaged or destroy-
ed, which certainly constitutes one of the most important points
of our art. Each tooth presents two very distinct parts:
1. One that is free, which is called body or crown.
2. The other which is implanted and concealed in the thick-
ness of the jaw, and differs by its length and by its simple or
multiplied condition, which is called root. That sort of con-
traction which separates these two portions is called the neck.
The crown has a different form, according to the species of
tooth we consider. Its summit is entirely flat, only when it is
worn by friction. In a perfectly sound tooth this summit is
raised by one or many projections called cuspides. Its circum-
ference is more round and projecting towards the exterior than
towards the interior. Its entire surface presents a whitish tint,
and brilliant glassy appearance.
The root, it has already been said, is simple or complex ; in
many cases it only offers the traces of a longitudinal division
which is not complex. Its form is that of an irregular cone,
connected near the basis with the adherent portion of the crown.
Its surface presents a yellowish hue, which contrasts with that
of this last. In a fresh state it is connected in an intimate man-
ner with the alveolar partition by means of the membrane of the
follicle.
The neck is formed in all the teeth, by the reunion of two
curved lines, the convexity of which is turned towards the
side of the root, and which meet each other by angles on the
sides where the teeth correspond. The circumference of the
basis of the alveolus does not correspond exactly to the neck,
but with the root at a certain distance from the neck. It is this
space that separates the neck from the alveolar border, which is
occupied by the gum.
The teeth have a vertical direction, or very near it ; we gene-
rally see, however, that the axis of the upper incisors is slightly
PATHOLOGY AND THERAPEUTICS. 25
inclined, so as to present a divergence beyond the centre of the
alveolar arches. When this obliquity is very marked, it gives
to the physiognomy a disagreeable character which resembles
the brute. The crowns of all the teeth present a length nearly
equal, and we can easily conceive the advantage resulting from
this disposition. If the teeth were separated far from each other,
mastication could not be easily performed. It is on account of
this that, in fractures of the jaw, the surgeon should use all
possible care to prevent a harmful consolidation of the fragments,
and the irregularity of the dental border which is the conse-
quence of it.
The teeth have, in general, the form of a hollow, irregular,
and rather elongated cone, whose large extremity is free and
projecting in the mouth, and constitutes the crown, and whose
summit, simple or complex, is sunk into the alveolus, and
constitutes the root. The conical arrangement of the root,
and the exactitude with which the alveolus is moulded upon it,
have this double advantage, that the effort of mastication is dis-
seminated through all the points of the alveolus, and that the
pressure is not felt at the extremity which receives the vessels
and the nerves.
According to form and custom, the teeth are divided into
incisor, canine, small and large molars.
The Incisors.
The incisors (cuneiformes of Chaussier) are those whose
crown have the form of a wedge, with the edge sHghtly fluted;
their office is, as their name indicates, to divide bodies that show
but little resistance. They are eight in number, four in each
jaw, two in the middle and two on each side ; they occupy the
front and middle part of each dental arch.
This class of teeth shows its peculiar powers most in vora-
cious animals, such as the wolf and the beaver.
General Character of the Incisors.
Their crown is compressed in the form of a wedge, a little
convex in front and concave behind, plain and triangular at the
sides. Its basis is thick, continued from the root; its edge free,
4
26 ANATOMY, ORTHOPEDIA,
a little larger than the basis, and cut obliquely at the expense of
the posterior part for the upper incisors, and at. the expense ot
the anterior for the lower incisors.
When the incisor teeth have not been worn by friction, they
present upon the edge three small unequal indentations, the mid-
dle one being a little more elevated than the side ones.* As to
their root, it is simple, flat on the side,of a conical shape, a little
thicker in front than behind, and sometimes marked on the sides
by a small longitudinal furrow ; we have even seen this furrow
penetrate deeply enough to bifurcate the summit and even the
whole of the root, which should be taken into consideration in
placing pieces on a pivot.
Difference in the Characters of Incisors.
The upper incisors are nearly twice as large as the lower ones.
The upper middle ones are much stronger than the side ones ;
but a character that should be particularly pointed out, and
which, however, the most critical anatomists, and even Cruveil-
hier himself, (whom we have so far taken as our guide in our
descriptions,) have omitted, is that the middle incisors have
an edged border completely straight, whereas, upon the side
ones, this border is cut obliquely from within outwardly; so
that the four incisors, united together, form, by their free border,
a straight line towards the centre, but shghtly inclined towards
the extremities.
In the lower jaw, on the contrary, the lateral incisors excel
the middle ones in magnitude, but this difference is scarcely
perceptible. As to their edged border, it is straight in the
middle, and rather crooked in the lateral teeth.
Canine or Laniar Teeth.
These teeth, conoides of Chaussier, called canirte, from the
fact of their being so marked in dogs, and laniares, because they
are so well calculated to tear in pieces— are four in number
* In the canine species this disposition is very manifest; it gives to the
tooth tlie Jltur de lis, which is more prominent as the animal is younger,
and as the tooth is less crown, as wc shall see in speaking of the wearing
away of the teeth.
PATHOLOGY AND THERAPEUTICS. 27
two in each jaw. Situated outside of the incisors, they are con-
sequently nearer the support and power which causes the lower
jaw to move, and are thereby enabled to overcome greater re-
sistance than the incisors, which are the extremity of the lever.
Hunter has named these teeth cuspidati, on account of their
pointed top. In carnivorous animals, their strength, however,
is fully developed. It is by these teeth that the bear, and even
the elephant defend themselves.* In certain fish, these teeth
are bent back in the form of hooks, and serve not to tear, but to
arrest swallowed up prey.
General Characters of the Canine Teeth.
These are the longest of all teeth, so that they hang over the
incisors a little, which is principally noticed in the upper
canines. Their crown is conoid, very convex in front, a little
concave and unequal behind, and ending with a pointed top
but most generally tuberculous, which very frequently over-
hangs the level of the other teeth.
Their root is simple, like those of the incisors, but much longer
and much more voluminous; the alveolus that encloses it has
quite a projection in front. Its extremity is sometimes separated
in two, but generally characterised by a furrow which indicates
two branches united in one, flattened on the sides. The neck
of the canine teeth shows, in front and behind, two very marked
curves.
Difference in the Characters of the Canines.
The upper canines are longer and thicker than the lower
ones, but in the lower jaw the neck of the canine and the
neighboring parts of its crown and of its root have a slight pro-
jection from the parabolical curve of the dental arch ; which is
the beginning of the relief we have already mentioned.
* Such, however, was not the opinion of Aristotle and Pliny, who say
thai the elephant has two great teeth between those which are used for eat-
ing, and who regard these two teeth as being of an altogether particular
nature. Duval has vainly sought to give some credit to this opinion, in a
notice inserted in the seventh volume of the Memoirs of the Royal Academy
of Medicine ; the opinion of Daubenton, corroborated by the researches of
Cuvier, is more generally admitted.
28 ANATOMY, ORTHOPEDIA,
The roots of the upper canines correspond to the ascending apo-
physis of the submaxillary bone, and in some individuals become
longer until they arrive at the basis of this apophysis. As these
roots are directed towards the socket of the eyes, some have
been ignorant enough to suppose that they were in some way
connected therewith, and in consequence called them eye flaps.
So evident is such an error that we scarcely deem it necessary
to combat it ; we will simply observe that the length of their
roots explains the difficulty frequently met with in their extrac-
tion, and, moreover, the accidents which may result therefrom.
The Molar Teeth.
The molar teeth have a cuboide crown, the end of which is
filled with tubercles, which are designed to grind like a mill.
Hunter calls them multicuspides ; but the small ones having
only two nipples, are likewise designated under the name of
bicuspides.
The molars are twenty in number, ten in each jaw. They
occupy the five last alveoli of each half of the dental arch, and
consequently are found nearer the point of articulation than all
the teeth, which gives them, as we shall hereafter show, a very
advantageous arrangement for having a powerful pressure upon
the bodies which any one wishes to crush against them.
Teeth of this class have, for general characters, in the first place
a flattening of the top of the crown, and, consequently, a much
greater extent of the triturating face than that of the two kinds
already described. Their faces are parallel, that is to say, do
not approximate to form a sharp or angular border. Their sur-
face is unequal and projecting ; their crown is round and a little
square, and rather short in a vertical sense. Their roots are
numerous.
General Characters of the Bicuspides.
We already know they are eight in number, four in each jaw,
two on each side, and occupying the space which is left be-
tween the canine and the big molars, so that a line that would
cut the orbit in two equal parts would fall into the interstice
that separates the second small molar from the first of the three
PATHOLOGY AND THERAPEUTICS. 29
large ones. Their crown is cylindrical, about as large as that
of the canine, connpressed according to the diameter which cor-
responds with the parabolical curve of the dental arch ; the
anterior and posterior /aces are even ; the two others, that is to
say, the internal and the externa], are convex.
The smooth extremity of this crown presents two short conoid
tubercles, one externally, a little larger, the other internally, sepa-
rated by a furrow which follows the direction of the arch. As
to the root, it is unique and bifid; but in the first case it is deeply
furrowed in its length.
Difference in Characters.
The small lower molar teeth are not so strong as the upper
ones, from which they moreover differ by the direction of the
crown, which is slightly bent in by the wearing out of the ex-
ternal tubercle. The first, a little smaller than the second, often
presents but a single tubercle, which is the external, an arrange-
ment which very often gives it some resemblance with the
canine it touches.
The tubercles of the small upper molar teeth are separated by
a furrow more marked than that which divides the tubercles of
the lower ones. In these they are sometimes reunited. The
second from above presents, in the majority of cases, two roots,
which makes it different from the others.
To find, as a modern author* has done, the reason of this
double root of the small upper molar teeth, in the fear that na-
ture had that they might fall, is truly a subtility which many
persons will be astonished to meet in a work given as a serious
labor.
General Characters of the Large Molar Teeth.
They are twelve in number, six in each jaw, three on each
side, and occupy the remotest part of the alveolar arch. The
last has received the name of wisdom tooth, on account of its
late appearance. Their crown is much larger than that of the
preceding ones ; its form is cylindrical, a little flattened on the
two sides by which they correspond with each other, but round
* Lekoulon : New Treatise upon the Art of Dentistry, page 29.
30 ANATOMY, ORTHOPEDIA,
and convex on the external and internal fronts. Their free and
triturating surface is covered with four and sometimes five une-
qual tubercles, cut into facets, separated by a crucial furrow,
and often by small dimples. Their root is always double or
treble, and in this case one of the branches presents a longitu-
dinal furrow, which indicates the union of two in one. Some-
times it is quadruple or quintuple, but varies according to
length and direction. These roots are sometimes diverging,
sometimes parallel ; and frequently, after wandering off, they
come together, and bend in the shape of a hook, which em-
braces a greater or less portion of the maxillary bone. When
the teeth present this disposition^ which is not very rare, they
are called barred teeth, they cannot be extracted without ex-
tracting at the same time the bony portion which they embrace.
All contrary pretension would involve an absurdity.
Difference in Characters.
The crown of the large lower grinders projects somewhat in-
side ; that of the upper is entirely vertical. The large lower
grinders are the only teeth that have a more bulky crown than
those which correspond with them above. It is easy to dis-
tinguish the upper from the lower by ascertaining the arrange-
ment of their roots ; thus, in the lower ones, the roots are two
in number, one in front, the other behind. These roots are
very strong, large, flattened from behind in front, rather deeply
furrowed according to their length, and bifurcated at the top.
The upper teeth have generally three roots, two external, which
are frequently united, and one internal, most commonly very
diverging.
The first large molar tooth is distinguished from the two
others by its bulk, which is generally quite considerable. Its
crown has generally four, and sometimes five tubercles, two
within and three on the outside. The second, not quite so
bulky as the first ; is attached to the lower jaw by four tu-
bercles, separated by a crucial groove, which is less regular in
the upper jaw, its body has a rhomboidal form.
As to the third large molar, or wisdom tooth, it is distin-
guished from the first and second by its bulk, which is some-
PATHOLOGY AND THERAPEUTICS. 31
what less at its crown, which has generally but three tuber-
cles, and at its axis, which considerably directed inwardly at its
roots, which are sometimes completely united in one. But in
this case we never fail to find in it all the characteristics of the
molar teeth, that is to say, the vestiges of three roots, blended
in one for the upper root, and in two for the lower one. Fur-
thermore, the wisdom tooth is that which contains more varie-
ties, and frequently, instead of taking a perpendicular direction,
it takes an oblique course, both inside and out, and instead of
presenting three or four tubercles, it only presents two or some-
times but one ; whereas, in some instances, we have seen its
crown divided into six, eight, and even ten tubercles ranged
in two lines, and separated by a furrow, or sufficiently deep
depression.* It is even sometimes found in individuals in
whom it remained buried in the thickness of the maxillary
tuberosity.
Structure of the Teeth.
But very few parts of the organization of man have en-
grossed the attention of anatomists more closely than the struc-
ture of the teeth. If we reduce to the most precise data, what
has been written on the subject of the teeth, we shall find that
they are essentially composed of two substances; one external,
hard or cortical, which only offer slight marks of organization,
that its resemblance with the general tissue of the bones gives
them the name of osteoide, and divides itself into ivory and
enamel; the other internal, soft or pulpous, deeply organized,
called pulp or kernel of the tooth.
Hence we see that the teeth are not full, but hollow near the
neck, and as far as the centre of the crown. This cavity pre-
sents nearly the form of the tooth upon which it is examined.
It is generally the more considerable the less the individual is
advanced in age. Frequently it is obliterated in the adult.
Closed on the side of the crown, it prolongs in contracting
more and more towards the summit of the root, and there opens,
following the number of roots through one or many holes
♦ Lemire givcSj in his Treatise upon the Teeth, a very curious example of
this sort. Wc have many of them.
32 ANATOMY, ORTHOPEDIA,
through which an artery, a vein, and a nerve pass. It con-
tains the pulp or dental papilla.
The hard, or cortical portion, is hkewise composed of two
substances, as Eustachius* has already demonstrated — one
that lines the crown, and only the crownf, with a vitreus layer,
of little thickness, and grows thinner as it approaches the neck :
it has been called enamel on account of its resemblance with
the glassy covering of the porcelain ; the other, which forms the
entire root, and the deep portion of the crown, is the ivory
which has also been improperly called dental bone.
The enamel is a particular substance, unequalfed in the econ-
omy, semi-transparent, principally in the teeth of first den-
tition, variable in color, not only in the same individual, but
even in the same range of teeth, from the white of milky or
bluish pearl, to the deep yellow, partaking even of the brown.
Its texture is eminently fibrous, which is easily perceived
when studied from the fragments of the crown, where it is
quite evident that the enamel is composed of short fibres,
which are a sort of crystalline needles, strongly pressed one
against the other, and raising themselves, not exactly perpen-
dicularly, but rather obliquely from the external surface of the
ivory.
Many modern authors seem to give this fibrous texture of the
enamel as an anatomical fact, the discovery of which they claim.
They are mistaken, for this texture has been long known : as a
proof thereof, we will merely quote the following passage from
Lahire, published about fifty years ago :+ "The substance of the
enamel is composed of an infinitude of small fillets which are
attached to the internal part of the tooth by their roots, almost
in the same way that the hair and nails are to the parts they are
connected with. This composition is very easily seen on a bro-
ken tooth, where we perceive that all these fillets are very much
inclined towards this part and almost perpendicular upon the
* EusTACHE : De Dentibus. Vide opuscul anatemi. 1574.
tAn anatomist, named Benin, believes, however, that the enamel ex-
tends in an extremely thin layer over the whole surface of the root • but
surely he has no authority for this assertion.
\ Memoirs of the Royal Academy of Sciences, 1699.
PATHOLOGY AND THERAPEUTICS. 33
basis of the tooth : by this means these fillets resist better the
efforts they are obliged to make in this place."
The enamel is extremely hard, and this quality is one of its
most powerful elements of stability. As long as the teeth are
covered with it, they resist the greater part of the causes of change
that arises from the bodies with which they generally have re-
lation ; but as soon as the ivory is exposed, they deteriorate* very
easily. In old skeletons, when all the other parts of the tooth
are reduced to dust, the enamel still preserves its consis-
tency and solidity. This extreme hardness causes the enamel
to be quite brittle ; and the sudden percussion of a hard body
is able to crush it, or to deprive it of its brightness.
The thickness of the enamel is very variable. In some per-
sons it forms a great part of the crowns of the teeth, while in
others it is found in very thin layers ; always thicker in an
adult than in a child, in the large molars, than in the canines,
and in the latter than in the incisors, it is more marked at the
triturating extremity of the tooth, and is worn with time by the
effect of friction, and almost disappears in old people.
Although Mascagnif considers the enamel as entirely formed
of absorbing vessels, it has nevertheless been hitherto utterly
impossible to discover the least trace of vessels. Injections
never penetrate it — the use of the madder never colors it with
red ; subjected to fire, it separates from the ivory, blackens
a little at first, tarnishes and becomes brittle after having resisted
a longer time than the ivory of which we shall soon speak.
By plunging the enamel into nitric acid, slightly tinged with
water, it dissolves, and assumes a whitish color. Scraped with
a sharp instrument, it is reduced to dust, which distinguishes
it from the ivory which is divided into very thin plates, and
forms a sort of chip similar to those obtained by planing wood
with a straight fibre.
The chemical analysis of the enamel has been frequently
* This assertion, however, ought not to be received in an absolute sense,
as we will show in the part devoted to pathology, when treating of caries
and the wearing aivay of teeth, etc.
t History of the Lymphatic Fessels of the Human Body, etc .
5
34 ANATOMY, ORTHOPKDIA,
made, but we consider the following of Berzelius as most satis-
factory. According to him it contains,
Phosphate of lime, 85.03
Carbonate of lime, 8.00
Phosphate of magnesia, 1-05
Animal matter and water, -20
94.28
The results obtained by Peppys, vary but slightly from these.
This chemist merely pretends with Hatcheff, and, contrary to
the analysis of Fourcroy and Vauquelin, that this substance
does not contain any cellular or cartilaginous tissue. We are
inclined to admit this last opinion, because it is founded on the
entirely inorganic appearance of the enamel.
The ivory constitutes, alone, almost the entire tooth of which
it forms the root entirely, and the body in a great measure. It
is neither as hard nor as brittle as the enamel. It is of a yel-
lowish white color ; its texture extremely thick ; neither fibres
nor cells are discernible in it, but it is easy to perceive a lamel-
lous disposition, particularly in the crown which appears evi-
dently to have been formed from co?icentric layers, of horns set
in each other, and parallel with the exterior surface of the tooth.
The root does not present, distinctly, this disposition. Its frac-
ture has generally a silky and variable appearance.
This part of the tooth is composed of calcareous and animal
matter, as is demonstrated by the analysis we intend to give of
it ; but the point that has caused most discussion, is to know
whether it possesses vessels or not. Blake* and Fox, relying
on ihe tumefaction and softness so remarkable near the root, to-
gether with the soldering which they imagined they observed,
with the alveoli, have come to the conclusion, that vessels
should be admitted into it. There are, however, strong and
numerous arguments for the adverse opinion. Thus it is evi-
dent that the injection does not penetrate it. Once formed, it
wears out by friction like an inorganic body without the least
appearance of a nutritive motion.
• DUsertatwn upon Dental Formation, etc. Edinburg, 1778.
PATHOLOGY AND THERAPEUTICS. 35
Beclard, unwilling to admit a vascular communication be-
tween the ivory of the crown and the dental pulp, thinks, ne-
vertheless, that the ivory receives continually from the latter,
a liquid by imbibition : that in consequence, it is in regard to
the pulp, in the same condition that the hair, nails, horns in
general, are in respect to the vascular part of the skin. As to
the ivory of the roots, we think that its texture, organic action,
and morbid alterations developed in them, with the further
proof of the vessel's continuous with those of the organism in
general, authorise the belief that the question is solved in favor
of their presence.
Whatever may be the organization of ivory, air cannot easily
penetrate it ; and, if subjected to the action of nitric acid, it
acts like the tissue of bones, that is to say, its calcareous sub-
stance is dissolved, and there remains in it a parenchyme, both
tenacious and flexible, having neither a fibrous nor an alveolary
appearance ; when, on the contrary, it is submitted to fire, it
burns in diffusing an odor that depends upon the presence of
the gelatine, becomes black, and leaves a white, hard, and
brittle substance.
Berzelius found in the ivory substance in one hundred parts :
Phosphate of lime, 61.95
Fluate of lime, 2.10
Phosphate of magnesia, 1.05
Carbonate of magnesia, 5.30
Salt and chloride of sodium, 1.40
Animal matter and water, 28.00
According to Peppys, the roots are formed of one hundred
parts of
Phosphate of lime, 58.0
Carbonate of lime, 4.0
Animal matter, 28.0
Water and loss, 10.0
Desirous of procuring a more recent analysis of the part that
constitutes the osseous tissue of the tooth, we have requested
Doctor Fory, professor of medical chemistry, and at present
principal apothecary in the Hospital of St. Louis, to have
the kindness to make it. This honorable chemist obtained the
following results :
36 ANATOMY, ORTIIOPEDIA,
B^r the ivory matter of the crown, free from enamel :
Phosphate'of hme, 61.93
Fluate of lime, 2.12
Phosphate of magnesia, 1-05
Carbonate of magnesia, 5-29
Salt and chloride of soda, 1-51
Animal matter and water, 28.00
For the root :
Phosphate of lime, 58.00
Carbonate of lime, 4.00
Animal matter, 3.00
Water and loss, 11-00
Hence the ivory differs much from the enamel, for it contains
a little animal matter similar to that of the bones, as is demon-
strated by these analyses, and as can be easily seen in many
preparations deposited amidst the collections of the faculty,
whereas the enamel is almost entirely calcareous. This pre-
sence of a cartilaginous matter in ivory, and its manner of acting
in regard to the caloric, which acts upon it precisely as it does
upon the bones, although insufficient to establish a similitude
between the ivory and the bones, are nevertheless daily called
in requisition, and will shortly be so for the purpose of explain-
ing certain diseases of the teeth, which are, notwithstanding,
all that can be said, the most striking resemblance with those of
the osseous system.
As to the union of the enamel with the ivory, Cuvier* pre-
tends that there exists between these two substances, a line
that terminates at the neck, and continues with the plate of the
follicle, which adheres to the root of the tooth. This learned
anatomist considers this line as indicative of the existence of a
very fine membrane, which envelopes the papilla, when no part
of the ivory is transuded. As this papilla gradually separates
from the ivory, it draws inwardly, and also separates from the
membrane, which always serves as a common tunic, both to the
membrane and to the matter which it transudes underneath.
The enamel on its part is deposited upon this tunic by the pro-
* Studies and Researches upon Bony Tissues.
PATHOLOGY AND THERAPEUTICS. 37
ductions of the internal plate of the capsule, and is in such a
manner compressed by it, that it soon becomes imperceptible in
the hard portion of the tooth, or at least appears on the cap of
the tooth only as a fine greyish line that separates the enamel
from the internal substance.
M. Duval has latterly very strenuously insisted on the im-
portance of this Hne, and M. Blandin* says positively, that he
has found, and announced in his courses, the membrane that it
represents. Blandin goes so far even as to compare the rela-
tive disposition of the ivory and the enamel of the teeth to
that of the osseous extremities and the cartilages of the articu-
lations, and considers the membrane of which we speak, as per-
forming the duties of the synovial which is placed between the
bone and the cartilage.
The soft portion or dental pulp, occupies the cavity which
exists in the tooth, and exacdy represents its form. It is, says
Cloquet,t a sort of ganglion, of exquisite sensibilit, following
the vasculary and nervous pedicule, which enters by the root,
and of which it only appears to be a rudiment. Being of
a greyish color, and a soft mucous substance, it is intimately
connected to the vessels and dental nerves by means of a vas-
cular and nervous pedicule which penetrates the root of the
teeth by the aperture that perforates its summit.
Blandin considers the pulp or dental kernel only a continua-
tion of the dental follicles. He uses the following language in
leference to the subject : "The dental follicles are placed in the
alveoli in the same number as the teeth. They are small sacs
formed by depressions of the mucous membrane on a level with
the neck of the tooth. Exteriorly they are intimately connect-
ed with the alveolar periosteum, and sink into all the anfractu-
osities of the alveoli ; interiorly, the follicle that comes out of
the alveoli is filled by the root of the tooth to which it strong-
ly adheres ; its buccal aperture embraces the neck and remains
there; its bottom gives birth to the papilla or pulpous kernel."
We insist on this opinion, because it corroborates what we
have already established, which is, that there is great analogy
* Anatomy of the Dental System, in respect to Man and Jinimals. Paris, 1836.
t Descriptive .Anatomy, with plates.
38 ANATOMY, ORTHOPEDIA,
between the dental follicle and that of the hair and of feathers,
or to speak in more explicit terms, between the tissue of the
teeth and that of the various epidermic productions. Both folli-
cles are formed by a fold of the tegumentary membrane ; both,
says Blandin, are principally connected to the neighboring parts
by a nervous and vascular pedicule ; both have a contracted
neck adhering to the organ which they produce, and surround-
ed by a follicular circle ; both give birth to a papilla; in fine both
enclose, the first the tooth, the latter the hair or the feather.
The only very sensible difference, continues the same ana-
tomist, which separates both follicles, consists in this, that the den-
tal is mucous, whereas the hair and the feather follicles are almost
always cutaneous, inasmuch as the first is sunk into the alveoli,
whereas the other is sunk into the general cellular tissue, and
finally, because the papilla of the dental follicle is pedicular,
whereas that of the piliform follicle in particular is sessile and
tubulous. This last difference explains the limited increase of
the tooth, and the indefinite development of the hair, as we
shall see when treating specially of the dental follicle in the
chapter devoted to the physiological history of the teeth.
To what has just been said let us add only that the swelling
that forms the dental pulp is penetrated by a great number of
bloody vessels and nervous fillets. The presence of the latter
explains the excessive sensibility of this pulp, to the irritability of
which a great many authors have attributed the various diseases
of the teeth, and even all that has been written on the sensibili-
ty and vitality of the teeth. Cuvier goes so far as to consider
it almost as delicate as the gelatinous substance of the pit of
the ear.
In an excellent dissertation, published in 1817, M. Serres,*
whose researches on this subject have served as a guide for
those who have since turned their attention to the apparel of the
teeth, has described a series of small bodies which he calls
glands of the teeth, and which are placed in a circle on the
alveolar borders around the neck of the foUicle.f These bodies
* Essay upon the Anatomy and Physiology of the Teeth.
t To be just, it is necessary to aver that Hippolytus Cloquet had written
upon them before Serres ; see his Traites upon Deacriptive Anatomy.
PATHOLOGY AND THERAPEUTICS. 39
are themselves small follicles that secrete a matter intended to
lubricate the alveolar border before the teeth come out, and
which, according to him, would afterwards form tartar.
This last supposition unfortunately falls before the observa-
tions of Em. Rousseau,* who, acknowledging the existence of
these glands, has, nevertheless, proved that they disappear after
the eruption of the teeth. These bodies exist effectively, we
are positive of it, but we think with Blandin, that these are
absolutely unknown to tartar, as we shall have occasion to prove
hereafter, and we believe they are more similar to the follicles
that are found around the neck of the matrix of the hair. De-
labarre acknowledges their existence ; but he thinks they be-
long to the nervous and salivary apparel, and that they secret a
part of the fluid intended to sustain the flaccidity and elasticity
of the gums.
Teeth of First Dentition.
The anatomical characters which we have described belong
exclusively to the teeth of adults, that is to say to those of the
second dentition. But in an infant of the age of two or three,
there are teeth of so different a character that we feel obliged to
examine them separately. Upon the precise knowledge of the
characters peculiar to them, practical facts of the highest import-
ance are established.
These teeth are called infantile or milk teeth, because they
are pecuhar to children, and make their appearance generally
when the child is at the breast. They are likewise called tem-
porary, in opposition to those we have described, and which are
called permanent.
The milk teeth are twenty in number, ten in each jaw. We
will merely designate the characters by which they are distin-
guished from the permanent.
Their color, instead of being an ivory white or of a clearyel-
low, is a bluish or azure white. The incisors and canine teeth
are always distinguished from the permanent incisors by a less
bulk and by the shortness of their roots, which frequently are
entirely destroyed, as we shall show when treating hereafter of
• Comparative Anatomy of the Dental System of Man and the principal An-
imals. Paris: 1827, 8vo., with thirty plates.
40 ANATOMY, ORTHOPEDIA.
the physiological phenomena, by aid of which both species of
teeth succeed each other.
The two molars, that is the small ones, differ widely from the
same teeth in the adult ; they approach very near to the large
molar teeth, from which they are distinguished by the small
height of their crown, which is cylindrical, and presents firm
tubercles to the triturating face, three of which are outside and
three in.
The small molar of the adult have generally only two tuber-
cles, and the large ones four, as already stated.
Considered in regard to their bulk and general arrangement
the infantile teeth present moreover the two following charac-
ters : like the permanent they are stronger in the upper jaw
than in the lower; but they do not form by their union, as the
permanent parabolical ranges, but two arches which resemble
the bows of a circle, and differ but little from each other.
The comparative chemical analysis of the teeth of both den-
titions also demonstrates that those of the first contain a little
less phosphate of lime than those of the second. It is to this
small quantity of salt we must attribute the transparency or
milky appearance, and principally the great alterability of the
milk teeth ; they are also frequently affected with decay when
falling out to leave room for others that succeed.
Finally to complete the history of the human teeth, consider-
ed in different ages, we annex an analysis made by Laissaigne,
professor of chemistry in the veterinary school at Alfort.
Animal matter
Phosphate of
Carbonate o
Objects submitted to analysis.
in one hundred
lime,
one hun-
lime, one hu
parts.
dred
1 parts.
dred parts.
Teeth—
Of a man 81 years of age,
33
66
1
Of an adult,
29
61
10
Of a child 6 years of age,
28.05
60
11.05
Of a child 2 years of age,
23
67
10
Of a child 1 day old.
35
51
14
Of an Egyptian mummy,
29
55.05
15
Cartilage of the gum
Of a child 1 day old.
86.07
11.03
2
Dental pulp
Of a child 1 day old,
77
23
6
Dental sac
Of a child 1 day old,
57
37
6
PATHOLOGY AND THERAPEUTICS. 41
Varieties and Anomalies of the Teeth.
The teeth, perfectly identical in both sexes, present numerous
varieties, and frequently very rrange anomalies. Blandin* at-
tributes these varieties to three circumstances : age, race and
individuals ; but as he is obliged to confess that races only im-
press upon the teeth insignificant varieties, and as the researches
to which we have a long time had recourse for the purpose of
making our collection one of the most complete, have convinced
us that the differences which sometimes exist in the teeth of
certain people are less the positive consequence of natural char-
acters than the result of certain habits, we will only admit two
orders of varieties : those that depend on age, and those that re-
late to individuals.
Varieties of Teeth according to Ages.
We have already traced some of the characters which the pro-
gress of life impress upon the teeth : we have now to present
the following considerations :
The root of a tooth is always developed differently from the
crown. In a very young child, the root, properly speaking, does
not exist, but the crown, on the contrary, has already nearly ac-
quired the size it should afterwards have. In a little more ad-
vanced age, the root is far from having attained its entire length,
still the crown begins to wear out at its extremity. In an adult,
some teeth have already lost, by use, the small projections with
which the top of their crowns are furnished, and their roots have
ceased for a long time to increase. Finally, in old age, the
crown is sometimes completely destroyed, while the root is
still completely perfect ; so that their natural destruction takes
place in the order of their development.
The shedding of the teeth follow the same order as do their
eruption. Thus, this prelude of destruction commences with
the incisors. Is it because being first developed, they are shed
before the others ? It is one reason without doubt ; but the thin-
ness of the summit of their bodies, and the frequency with which
they are used in man are likewise two perfectly admissible rea-
sons ; the enamel furthermore is not so thick at their extremity as
upon the other teeth.
* Work quoted
6
42 ANATOMY, OIITHOPEDIA,
At the expiration of a certain period, which varies according
to a number of circumstances, but particularly according to the
condition in which the teeth are after their formation, the small
nipples with which the tops of their crowns are mounted have
disappeared, and with them all the enamel that covers their sum-
mit. It is this condition we allude to when speaking of a tooth
that is rased. In this case, the centre of the triturating surface pre-
sents a yellowish hue, and its circumference is surrounded by a
line of a white color.
In proportion as a person advances in age, the wearing of the
teeth progresses. In old age, it frequenUy removes the entire
crown, without, nevertheless, the dental cavity being opened ;
this depends, as we shall soon hereafter see, on a new deposit of
bony matter wiiich presents itself like a stopple to protect the
cavity.
Hence, it necessarily follows from what precedes, that teeth, in
the same degree as they are worn away, should furnish positive
data for the determination of ages. This can be exactly ascer-
tained in animals who have uniform food or a regular way of
living ; but it would not be so in a man whose food is as va-
rious as his tastes, and on whose teeth are impressed diseases
which modify their composition and render their destruction
more rapid. In considering these circumstances we are enabled
to obtain results of much importance. We will soon return to
this question.
Varieties of Teeth according to Individuals.
There is certainly no organ that offers so many varieties as
the teeth. In order to conform with the general order, we will
refer these varieties to five principal heads — to number, form, di-
rection, position and structure.
Varieties in number ; These are either varieties by default or by
excess. The first consist either in a total absence of teeth , as Fox,
Borelli, Labatier and Baumes have quoted examples, or in the
absence of a great many, as in a subject that we have known
who only had in each jaw four incisors, and as Schmitt and
Fauchard have observed ; or, in fine, the absence of one or two
teeth only, a conformation which appears hereditary in some
tamilies, sometimes it is a canine, again an incisor, which has not
appeared.
PATHOLOGY AND THERAPEUTICS. 43
It is not unfrequent to find individuals, particularly women,
whose wisdom teeth never appear, especially in the lower jaw ; but
generally in this case the tooth remains concealed in its alveoli, or
in the thickness of the branch of the jaw, and finally comes
out, for we think that a slow tooth is, if not the agent, at least
the motive of an effort of expulsion which ceases only at its
egress.
We will remark that the anomaly in the development of teeth,
which goes so far as to leave the jaws entirely naked, is extreme-
ly rare; we have never seen it personally.
As to the absence of one or more teeth, we frequently observe
it in the large molars, and in some cases, we repeat it, their fault
is only apparent, and depends only on the fact that they remain
enclosed in their alveoli beyond the time when they generally
appear. Doctor Devaut* furnishes an example of one of his fel-
low students who died at the age of eighteen, in Paris, with five
teeth less in the lower jaw, three molars on the right and two
on the left; his gums were large and swollen, undoubtedly on ac-
count of the germs they contained, and did not present the edged
border which the gum of the newly born offers. He never re-
members having had any teeth at this place, and never were any
extracted from him. It is furthermore said that a magistrate of
Frederickstadtf never had any but molars, and no canine or
incisors.
Fauchard has left us the curious observation, of a child five or
six years old, in whom the greater part of the teeth had not ap-
peared. Brouset, in his excellent Treatise on the Medical Edu-
cation of Children^ likewise speaks of an individual of the age of
twelve, who only had the half of his teeth, and whose alveolar
border had acquired the consistency of the gums of an old person.
Finally, there is no tooth whose absence has not been either
separately or conjointly with others observed. The decrease
of the number of teeth because two or more of them are uni-
ted together, is a rare anomaly ; but we think it less inju-
* Essay upon the JYalure and Formation of the Teeth : Inaugural Thesis.
Paris, 1826.
fSee iheEphemerisoftheJyatureoflhe Ctirious.
f Volume first.
44 ANATOMY, ORTFioPBniA,
rious than their absohite absence, for we have met with many
examples ; we have, amongst others, two incisors on the same
side imited in such a way that in reahty they form but one.
What is hard to admit is the reunion of all the teeth in the
same jaw : the examples of this sort related by Pliny, Plutarch,
Bartholin, xMelanthon and some other authors, historians or
naturalists, are probably nothing else but facts badly ob-
served.
As to the union of two teeth in one, this is done either by
the crown or by the root, or in fine by both. The first case is
more common for the incisors, and the second for the molars ;
and in carefully examining the examples of this last case, we
are compelled to admit that there is not always direct adhesion,
but connexion through means of the ossified dental alveolar
periosteum ; that is to say, that it is a sort of ankylosis formed
by the union of the roots of both teeth through the inter-alveo-
lar partition, afterwards destroyed by the inflammation of the
dental alveolar periosteum.
The union of the crown, on the contrary, is a real fusion of
the two teeth, in which the ivory substances are common to
each other. It takes place when the teeth are still in an em-
bryo state : two germs have been formed very near each other —
the intermediary portion is not developed — they then remain
in the same alveoli, their two papillas are confounded together
and the calcareous layers, after being extended over this dou-
ble papilla, separated for the purpose of forming the roots of the
confounded teeth. If we form our judgment by the cases
which we have observed; the union of the canine with the
lateral incisor, would be much more frequent. This is explain-
ed by the strong pressure which the canine always exercises
upon the lateral incisor from its formation.
The excess of teeth always depends on the duration of those
of first dentition. Likewise those teeth which are called super-
numerary; whether they appear separately, or whether they
form a complete series, almost always show themselves behind
the others. There are, nevertheless, circumstances in which we
are obliged to admit the existence of third germs in the jaws.
Such undoubtedly was the case of the son of Columbus, the
PATHOLOGY AND THERAPEUTICS, 45
anatomist, and that related by Serres* of a servant of Geoffrory,
physician in the Hotel Dieu, who had a double range of teeth,
forty in all. We are frequently deceived in regard to the ex-
istence of the supernumerary teeth. We have frequently, by
inspecting the mouth, proven to persons who imagined they
were thirty years of age, that they were deceived by simple
appearances.
Finally, a variety of teeth which comes under this class, is
simply the internal existence of supernumerary teeth. We
have many examples in our collection : in one, the tooth is stop-
ped between the roots of a large molar : it is represented in
plate 8, in the work of Maury, to whom we have entrusted
it ; in the other case, it is developed in the cavity of another
tooth, which it has split : in a third, we see a cell in the thick-
ness of the upper maxillary, immediately beneath the nasal
bone, on the very line of separation of the two maxillary bones.
Variety in the Form of the Teeth.
It is reasonable to consider the most part of the varieties of
form the teeth offer, as results of a morbid state, which has
affected them at some period of their development. But we
can likewise admit that a simple pain could have determined
some of the various and capricious forms they offer in. many
cases.
Sometimes there are teeth of immense size, or of extraordi-
nary smallness ; sometimes we meet upper incisors, bent up
wards in form of a hook, or having a double hook. Some
likewise diverge from the crown and the root towards the neck,
in form of the letter Z ; whereas, others bend in the form of C.
We, moreover, find crowns surmounted with an unfinished tooth ;
finally, crowns absolutely deprived of roots, and roots of crowns.
But in enumerating all the varieties of form we have in our
possession, we are compelled to admit that the extreme affinity,
and the excessive divergence of the roots of the large molars
are, if not the most remarkable, at least the most common ; for,
in twenty teeth of this kind, we do not frequently meet with four
* Memoir quoted, page 134.
46 ANATOMY, ORTHOPEDIA,
that have the same form. We should observe tliat these varie-
ties of roots are seldom seen, if ever, iii the milk teeth.
Finally, a variety of form that is common enough, and which
has not been remarked by any author, is the depression in form
of a horn, from the posterior face of the anterior teeth, and of
which the enamel has perfectly followed the contours.
Varieties in the Direction of the Teeth.
As these varieties are frequently accessible by the means of
art, we will return to them by-and-by. In the mean time, let
us here observe, that authors are much mistaken in saying, that
these anomalies of direction are sufficiently rare ; for, from the
simple obliquity to a complete inversion, there is a number of
bad directions, which it is useful to know, together with their
causes, and which might possibly be corrected.
Varieties of the Position of the Teeth.
The annals of medicine exhibit very remarkable examples of
the transposition of the teeth. It must certainly be interesting
to the surgeon dentist to know something of it; for, this
knowledge may be his guide in the appreciation of a tumor de-
veloped in the vicinity of the dental arches.
This variety consists in a simple deviation of the position
which the tooth naturally occupies, but there is also sometimes
a complete transposition — a real error in position. The first
case is well explained by the improper directions which the
teeth may assume ; those particularly of the upper jaw, which
sometimes leave the alveolar border, either to be transferred to
the side of the palate, or in any other direction, or to be placed
entirely across the alveoli. But it is difficult to explain the
cases of complete transpositions, or rather they cannot be ex-
plained ; they may be observed and noticed. Here is a sum-
mary detail of the anatomical pieces, the most remarkable of
this sort is in our collection :
1. In an adult, a canine, on the right side, which is placed
across the arch of the palate, adhering to the partitions of the
PATHOLOGY -AND THERAPEUTICS, 47
alveoli which contain the two incisors and the small canine,
but without any communication with these alveoli.* A den-
tist of the last century, found an almost similar case in an or-
ganist of Payenne ; but the tooth, instead of being a canine,
was a molar; and, instead of adhering to the alveolar partition,
it occupied the very centre of the palatinal arch.
2. A canine on the right, and of the second dentition, which
remains in its alveoli, but continues to increase towards the
wings of the nose, and having, by the development of its
crown, burst the alveolar partition, at the expense of which it
was produced.
3. A canine that lies across the anterior part of the palatinal
arch, adhering to the alveolar arch of which it destroys the
entire plate to the extent of nearly three centimetres.
4. Two wisdom teeth, of which are entirely enclosed in the
thickness of the branch of the maxillary bone, bursts the ex-
ternal partition ; the other only showing a light part of the
crown in the thickness of the base of the coronoid apophysis,
but directing itself from behind in front, and not from above
downwards.
5. A small molar having completely perforated the body of
the lower jaw, above the mental foramen, having its crown
perfectly formed, and its root equally perfect, but bent poste-
riorly.
Varieties in tJie Structure of the Teeth.
Those varieties of which authors are merely pleased to an-
nounce the possibility, without furnishing a single example,
are sufficiently numerous, and depend, it is true, frequently on
morbid causes. The most curious we possess of them is the
incrustation of a root of an incisor by a layer of enamel, but
the deposit, on different points of the roots of many molars, of
small particles of enamel, which seem to escape from a brush
intended to cover the crown with this greenish varnish ; Doctor
Devautf says that he has seen an example of this last case at
* CoLENDRE : see Essmj upon the Most Frequent Diseases of the Teeth, and
upon the Proper Means to Prevent and Cure them. 1781.
t Thesis quoted.
48 ANATOMY, ORTHOPEDIA,
M. Dumontier's of the Faculty of Paris. In this sort of varie-
ties should be put not only this unequal distribution of enamel,
which often presents lumps, hollows, holes, but, moreover,
the exostoses which so often develope on the roots, the com-
plete obhteration of the dental canal, the formation of the osselet
which prevents the opening of this cavity, finally, the trans-
formation of a tooth into a cartilaginous tissue, as we have many.
THE MAXILLARY BONES AND THEIR ALVEOLAR BORDER.
After the teeth, the parts of anatomical study most important
to the surgeon dentist, and of which the conformation should
always be present to his memory, are the maxillary bones, in
which they are planted. These bones are three in number,
two above and one below. The two first form, if not the whole,
at least the greater portion of the upper jaw. The other, by
itself, forms the lower jaw.
Fixed immovably to the bones of the skull, the two upper
jaws form, by their reunion, the middle part of the face. Con-
sidered in all they possess of importance to the dentist, each of
them offers two very distinct portions — a vertical one, called
ascending apophysis, and by means of which they lean upon
the frontal bones in forming the contour of the anterior aperture
of the nasal bones — the other is horizontal, and forms the body
of the bone ; let us enlarge upon this a little.
The body of the upper jaw presents three faces, one external,
one internal, and one above. The external face commences
at the point of junction of the two bones upon the middle line,
presents from the front behind, at first, a small cavity, in which
the mystyform muscle is inserted, and which is directed out-
wardly by the projection made by the alveolus of the canine
tooth ; afterwards, another cavity, of greater depth, called the
canine cavity, surmounted by the orifice of the suborbitary
canal ; finally, further behind, a vertical top that separates the
canine cavity from the maxillary tuberosity; this, evidently
more projecting before than after the appearance of the wisdom
tooth, is deepened by small conduits for the passage of the ves-
sels and posterior and superior dental nerves. Tlie anterior
PATHOLOGY AND THERAPEUTICS. 49
part of this face corresponds directly in front to the upper Up,
and at the sides to the soft parts which constitute the thickness
of the cheeks.
Of the other two faces of the upper jaw, the upper one, which
is of less extent, forms almost the whole of the orbit ; the other,
which is called naso-palatine, is itself divided in two unequal
parts, one of which, situated above, larger behind than in front,
forms a part of the platform of the nasal bones ; and the other,
situated below, forms a part of the palatine arch, to which we
will shortly advert. It is in this part of the internal face that is
seen the orifice of the maxillary sinus, a large orifice upon an
isolated bone, and which, upon an articulated bone, is straiten-
ed by the prolongations belonging to the neighboring bones.
This orifice leads to the interior of a cavity called maxillary
sinus.
This cavity, which makes the bone we are speaking of very
light, considering its bulk, has the form of a pyramid, of which
the basis corresponds inwardly, the summit outwardly, the up-
per partition to the platform of the orbit, the anterior to the
canine cavity, and the posterior to the maxillary tuberosity. If
the extreme thinness of the upper wall explains to the surgeon
dentist the influence of tumors developed in the sinus, on the
condition of the organs contained in the orbitary cavity, the
small thickness of the partition which separates below the bot-
tom of the alveolus fi'om its cavity, should also admonish the
surgeon dentist that they can be easily penetrated by these
alveoli, particularly by that of the canine, in perforating it to
place a tooth on the pivot.
Of the three borders of the upper jaw, the anterior, in unit-
ing with its mate, forms the projecting line that is seen be-
tween the two central incisors ; the posterior vertical is very
thick, but less so than the inferior or alveolar, which is the firm-
est part of the bone of which it forms in a measure the basis.
With this diff'erence from the upper jaw, the lower jaw is
composed of a single bone. This bone which occupies the
lower part of the face, has the form of a parabolical curve upon
both extremities, which are called branches, form a right angle
with the central part called body. This body represents a bent
7
50 ANATOMY, ORTHOPEDIA,
plate, convex in front, concave behind. Its anterior face offers
to the middle part a vertical line, called symphysis of the chin ;
it is the mark of union of the two parts of which this bone is
composed in young persons. This union is characterised in a
man by the form of an arc instead of an angle ;* and again, by a
vertical line instead of an oblique direction behind and almost
horizontal; thus, the chin is an exclusive attribute of the hu-
man species. The symphysis terminates in front by a triangu-
lar eminence, called mental, whence proceeds a line obliquely
directed above to continue with the anterior border of the branch
of the jaw.
The posterior face of the lower maxillary is moulded in some
way upon the tongue ; it presents like the anterior an oblique
line which is directed equally behind and above, and becomes
more projecting at the level of the last molar ; beneath this line
is a large depression, but one that is rather superficial, which
contains the submaxillary gland, and above a cavity that re-
ceives the sublingual gland. The two oblique external glands,
together with the oblique internal, divide the body of the max-
illary bone in two parts, one superior or alveolar, the other infe-
rior or basilary. The first constitutes, almost by itself, the body
of the bone in the fcetus and in the child ; but it only forms the
two-thirds of its height in an adult, whereas it disappears almost
entirely in old age, when this body is, in a great measure, reduced
to its basilary portion.
The branches of the lower jaw are quadrilateral. Their ex-
ternal face is covered by the masseter muscle, which is its prin-
cipal mover; the internal connects with the pterygoid muscle,
and presents the orifice widened by the lower dental canal.
But what is of importance to us to know and appreciate is the
union of these branches with the body of the bone. The angle
• But it does not follow that this character will be exclusive to the human
race, as many anatomists have said, for it belongs to many animals; the
ape, a large number of dogs, the cat, lion, and many others, have evidently
the inferior jaw arched, in such a manner that if an anterior part of the
lower jaw being found angular, one might affirm that it never belonged to
man; it would be imprudent to conclude the contrary, for the simple
reason that the two parts which compose it unite and form an arch.
PATHOLOGY AND THERAPEUTICS, 51
that results from this union, and which is called angle of the
jaw, is extremely obtuse in a child ; it becomes completely
straight in the adult, and reassumes in old persons the aperture
it has in a child, not by the retrocession of the articular con-
dyle, which, forming the centre of the movements of the jaw,
remains invariably fixed in the cavity that is peculiar to it, but
by the progress of the body of the bone. It is this progress
which, joined to the alveoli, explains why it is that the chin of
old persons is so projecting.*
This variation of the body of the jaw and of its branches, de-
termined by age, proceeds simply from the fact that at both ex-
tremes of life the two jaws intending to touch each other, it was
necessary that their branches and their bodies should be almost
on the same line, whereas, in the adult, the branches should
raise each other in order to remove the jaws from each other,
and of leaving between them the interval necessary to the teeth.
Hence arise, 1st, the repugnance adults have for eating, those
who have no teeth I mean. 2d. The impossibility of placing a
set of teeth in the mouth of a child, and the precautions we
should use in placing one in the mouth of an old man, whose
jaw has followed its natural evolution.
Examined in their mutual relations, the two jaws present
each, under the form of a parabolical curve, an alveolar border,
in which are placed the teeth that seem to connect with it, and
show themselves by exterior projections that give to this border
a festooned appearance. The upper curve is greater than the
corresponding alveolary curve of the lower maxillary bone, and
we have already seen what the consequence has been for the
mutual disposition of the teeth in both jaws. Each of these
borders, less thick in front than behind, where it projects in-
wardly, is surrounded by a series of holes, separated by their
partitions. These are the alveoli, whose dimensions are propor-
tioned to the roots they should contain, and which are sub-
divided like roots into two, three or four secondary cavities.
In the upper jaw, the bottom of these alveoli approximate the
* Bichat has erred, as M. Serres very judiciously remarks, in saying that
the branch of the inferior jaw inclines as much more from the perpendicular
as we observe in more advanced age.
52 yiN ATOMY, ORTHOPKDIA,
maxillary sinus, from which they are separated only by a bony
partition of extreme thinness, and in which they sometimes
open : this is principally applicable to the canine teeth. On the
upper alveolar border, principally in front, we can observe pro-
jections that correspond to the alveolus, and depressions that
correspond also to the interalveolar partitions. At the moment
of birth, the upper maxillary bone, which then is not very high,
is specially formed by the alveolar range that contains the germs
of the teeth, and are almost contiguous to ihe platform of the orbit.
As to the border of the lower jaw, it begins to exhibit itself
at a period very near conception. The alveolar borders of
each jaw subsist, in the course of life, on the important changes
that arise from the eruption of the teeth of first and second
dentition, and afterwards from the fall of teeth in old men ; a
fall that causes quite a decrease in their height.
Examined in the skeleton of an adult, the alveoli have, in
general, a conical form, and are moulded exactly on the roots
of the teeth for which they are destined. Their aperture is
necessarily directed upwards, in the lower jaw, and below in
the upper ; their bottom is pierced with holes that communicate
with the dental conduit, and that serve to transmit to the folli-
cle of the tooth, the nervous and vascular pedicle intended
for it; the thickness of their partitions differs according to the
species of teeth which each one of them contains. Thus the
incisors of the upper jaw have alveoli thinner than those of the
other teeth ; those of the canines are stronger, thicker and deeper
than those of the incisors, and even of the small molars ; the
first large molar has alveoli stronger than those of the second
and last, or wisdom teeth.
In the incisors of the lower jaw, there is a similar disposition,
and it is this that makes these teeth yield more easily to the
blows they receive, and they also yield more easily to the efforts
of the operator who extracts them. The alveolus of the first
large molar, is not as strong as that of the second and third.
The wisdom tooth, on the contrary, in the lower jaw, presents
the strongest and thickest alveolus of all, because it is found
deepened in the thickness of the coronoid apophysis.
It is, moreover, useless to observe, that the alveoli are pre-
PATHOLOGY AND THERAPEUTICS, 53
cisely in proportion as to capacity to the teeth for which they
are intended, and that, consequently, small for the incisors, a
little larger for the canine ; they acquire their summum of de-
velopment in the region of the large molars.
The partitions of the follicles of 'the teeth are confounded
outwardly with the periosteum of the alveoli which forms the
principal means of union of the teeth with the alveolar pro-
cess in the normal state; union, whose intimacy causes the
resistance and the principal strength of the teeth. It must not,
however, be disowned, that this union is powerfully seconded
by the perpendicular pressure which the teeth exercise towards
each other, when the jaws are approximated : the proof of this
action is acquired by the apparent elongation of each tooth,
when the opposite one is missing, which very commonly oc-
curs. There is, in this case, a simple eccentric motion of the
tooth, but not a real increase in length. This last phenomenon
is observed in certain animals, and not in man.*
It sometimes happens that the teeth are retained in their al-
veoli much more solidly than we have just stated, from the
fact of a particular arrangement of which we have spoken, in
treating of the molar teeth. In effect, the summit of the cone
of the roots may be bent in form of a hook, and fixed upon
a projection from the bottom of the alveoli. The roots of
the alveoli, as we well know, can likewise be strongly diverg-
ing, and form, in this way, a sort of nipper, with bended
points, and adhering to the line. Finally, by an entirely con-
trary arrangement, the roots of the same molar teeth are occa-
sionally convergent, and intercept, completely, a bony portion
that seems to be connected with them.
When a tooth has been withdrawn from the alveoli that con-
tained it, this cavity soon sinks, so that it is no longer possible,
after a certain period, to discover any vestige of it. And in ef-
fecting the occlusion of this cavity, not only does the alveolar
border sink, but also the bottom of the alveoli rises a litde.f
* See Memoir of M. Oudet, published in 1823, upon the Continued
Growth and Reproduction of the Teeth of Rabbits. We shall soon have to
refer again to this memoir, and to the phenomena to which it is devoted.
fThis fact is rendered evident by the prompt extraction, in certain cases,
of dead teeth placed in alveoli recently empty.
54 ANATOMY, ORTHOPEDIA,
In the jaws of new born infants, the alveoli have not yet
attained their development; there are ten or twelve in each
jaw ; they are very small, not very deep ; formed by partitions
extremely thin, and presenting to the exterior as many platings.
Each alveoli contains a dental germ.
Hence it follows that the alveoli serve to fix the teeth, and
furnish them with the requisite solidity to accomplish the action
of mastication, and to resist exterior violence. Their method
of union with the teeth, is unique in their organization : it is
not an articulation, but a simple implantation.
Summary Anatomy of the Gums.
However solidly fixed the teeth may appear by the juxta po-
sition of the alveolus around their roots and their neck, nature
has thought proper to increase the firmness by a fibro cellular
tissue, sufficiently thick, that covers both faces of the alveolar
borders, and even penetrates into the alveolus.
To this tissue is given the name of gum. Anatomists ap-
pear to see in it but a portion of the mucous membrane, which
is distinguished by its intimate adherence to the periosteum by
its thickness, and principally by a coriaceous density, almost
cartilaginous, a density that enables it to resist the contact of
hard bodies subjected to mastication. No doubt, then, that the
gums have much analogy with the portion of the palatinal mem-
brane which is near to them. They are arranged thus :
They commence at about two or three millimetres — a line or
a line and a half — from the basis of the alveoli, where their
limits are marked by a relief of festooned appearance. Having
reached the free border, or the basis of the alveoh, they continue
their passage in the space of two millimetres, as far as the neck
of the tooth. There they reflect upon themselves, and the pre-
cise place where this reflection is effected is a free semilunar
border, imitating the indented border represented by the bases
of the alveoli. Those slight slopes correspond to the intervals
of the teeth between which the portion of gum which the ante-
rior face of the alveolus communicate with that which lines the
posterior face.
PATHOLOGY AND THERAPEUTICS. 55
The reflected portion of the gum corresponds, without ad-
hering to it, to the root of the tooth in all the parts of this root
which grows over the alveolus, then sinks into it to constitute
the dental alveolar periosteum, which we know is a powerful
means of union between the root and the alveolus.
The tissue of the gum, firm and elastic, presents a color of
pale vermilion. It appears furnished with follicles, but which
we persist in believing foreign to the formation of tartar. It va-
ries much in color and density, according to individuals. One
of its most marked characters consists in the special action exer-
cised over it by scorbutus and mercury, under the influence of
which it softens and become spongy and bloody.
Another character of this tissue, but one that is entirely ana-
tomical, consists in apertures very much developed, which are
seen by a naked eye on a fine day. Almost insensible when
divided by a sharp instrument, it nevertheless creates serious
accidents when under the influence of the pressure exercised
by the teeth.
The tissue of the gum contains very little cellular tissue, pro-
perly so called. It is, however, susceptible of being easily swal-
lowed by delicate women, and also by lymphatic individuals,
and all persons who dwell in low, damp places; this indicates a
great permeability. Furnished with capillary vessels sufficiently
developed, which, by the pressure of the finger, causes it to ex-
perience the discoloration of erysipelas in sanguine and vigorous
individuals, and to preserve the clammy depression of the ode-
ma in those who are weak and cachectic ; this tissue forms
at the neck of each tooth a small pad, whose thickness depends
on the robust health of the individual.
In subjecting the gums to a convenient maceration, we per-
ceive in their tissue three layers or distinct membranes. The
mucous membrane forms the first, at the same time that it con-
tinues in the digestive apparel. Afterwards, a sort of pulpy
substance is detached, which composes the second layer; and
finally we perceive that the third is entirely distinct from the
others, by its tissue, which appears of a fibrous nature.
This last tissue is prolonged as far as the interior of the alveoli,
and forms in it sacs or matrices of teeth which are found her-
56 ANATOMY, ORTHOPEDIA,
metically closed by the pulpy substance, which is placed over
them. It is then also accompanied by the mucous or first
layer, which is introduced between it and the collar of the
teeth and gives birth to the generating pulp of the teeth, as the
skin forms that of the nails and hair.
The fibrous tissue, of which we have been speaking, is very
probably that indicated by Bichat, in saying that in the foetus,
and before the eruption of the teeth, the double border is cover-
ed with a particular tissue, very thick and very firm, that this
tissue covers the alveoli and exactly obliterates them, as well as
the dental germs which they enclose. It is undoubtedly this tis-
sue that Serres and Meckel* have described by the name of den-
tal cartilage, and whose destruction takes place at the first denti-
tion. But how can we reconcile this opinion with what happens
in the old man after the loss of his teeth.
Does this pretended cartilage reappear then ? or do the gums
return to the condition in which they were in early infancy ?
This last opinion seems to us most admissible.
Independent of all that has been written on the organization of
the gums, it must be admitted that this part of anatomy has not
been as fully investigated as it might be, and that the researches
hitherto made on this subjeot have not been as clear and precise
as might be desired.
To complete the anatomical history of the dental apparel, con-
sidered in a general way, it now remains for us to give a descrip-
tion of the nerves, arteries and veins that lead to the three parts
of this apparel.
Nerves and Vessels of the Dental Apparel.
Nerves. — The nerves that are distributed in the teeth and jaws
are supplied by the fifth pair of the nerves of the skull, general-
ly known by the name of trigemini. The upper teeth and the
upper jaw receive theirs from the second branch of these nerves,
or the middle branch of the upper maxillary. They are the pos-
terior dental alveolar, and the anterior dental alveolar.
* Manual of General and Descnptive Anatomy, ttanslaled 1823, by Bi-
chat and Jourdaia.
PATHOLOGY AND THERAPEUTICS. 57
The first two, sometimes three in number, are detached from
the upper maxillary, sometimes by a common trunk, sometimes
alone, when about to connect with the suborbitary canal are forced
in front and below, furnish fillets, which are distributed into the
muscles of the face and the tissue of the cheeks and gums. They
are afterwards received into canals made in the thickness of
the maxillary tuberosity, and then present themselves under the
appearance of small ribbons ; one of these branches, known by
the name of superior posterior-dental, crosses the basis of the
maxillary tuberosity and joins the level of the canine fosse by a
fillet provided by the anterior dental ; it gives several fillets that
pierce the substance of the bone to furnish the roots of the three
or four last molars. The posterior inferior dental, stronger than
the superior, crosses a crooked passage under the maxillary tu-
berosity and joins at the level of the canine fosse, to the posterior
superior dental. From their reunion arises a great number of
fillets, which form a considerable quantity of networks; the fillets
coming from these networks are included in the thickness of the
bone, but nearer the internal surface of the sinus than the ex-
ternal surface of the maxillary bone ; they furnish filaments that
are extremely thin, and which enter the small molars.
The anterior dental alveolar arises very large, from the upper
maxillary a little before it leaves the suborbitary canal. It after-
wards enters a canal provided by the upper maxillary to be reflect-
ed on the platform of the nasal bones. Having arrived at the level
of this base, about a millimetre from the orifice, it spreads out in
a great number of fillets, some of which go up, others descend.
The latter reflect from below upwards in the thickness of the
front nasal bone, where they disappear; the first terminate in
providing the incisors with dental nerves, also the canine and
even the first small molar. Many fillets also disappear in the
thickness of the bone.
The lower teeth and lower jaw receive their nerves from the
lower maxillary, the strongest and deepest portion of the three
branches of the fifth pair. This nerve is forced outwardly and
a little in front, leaves the cranium by the round hole which
bears its zygomatic fosse, where it instantly divides in seven
branches — of these branches, three are external : the temporal
58 ANATOMY, ORTIIOFKDIA,
profound, the inasseterieii, and the buccal, one is internal, which
is the pterygoidian ; finally, two are inferior, the lingual and the
dental inferior, which is the true termination of the lower maxil-
lary. We will here treat of the lower dental.
This nerve more voluminous than the lingual, is positively to
the lower jaw what the portion of the maxillary nerve, known by
the name of suborbitary nerve, is to the upper. It descends with
the Ungual between the internal pterygoidian and the branch of
the lower jaw; it afterwards connects with the dental canal,
which it crosses with the dental nerve, and furnishes in this
passage a filament to each root of the large and small molars.
Having arrived at the level of the hole of the chin, it sepa-
rates in two branches — one is called mental, the other incisor.
The first being considered, on account of its bulk, as a contin-
uation of the upper dental, leaves the hole of the chin and spreads
out in diverging fillets, which act in respect to the lower lip like
the suborbitary in relation to the upper. The second, extreme-
ly thin, follows the first passage of the lower dental, and divides
for the purpose of supplying the canine and the two incisors.
As to the gums, independently of the nerves furnished them
by the upper and lower dentals, they also receive them from the
palatine, facial, and ganglion naso-palatine, discovered in 1815,
by Hyppolite Cloquet.
Vessels. — The arteries of the dental system go regularly with
the nerves, and come from the internal maxillary. Those that
repair to the teeth and upper jaw are the alveolar or dental, and
the suborbitary which proceed with the buccal to the deep ante-
rior temporal, at the level of the maxillary tuberosity.
The first being forced very flexibly in front and below, is di-
vided into many branches ; they are the gencival and periostic
branches, which, having arrrived at the basis of the alveoli, re-
flect around this basis to insinuate itself into their cavity and to
be distributed in their periosteum ; then the posterior dental
branches, which are connected with the small dental canals, pen-
etrate into the alveoli of the molar, large or small, and divide
into as many small branches as there are roots. The second
which sometimes proceeds from a common trunk with the alveo-
lar, connects with the suborbitary canal, and leaves it for the pur-
PATHOLOfSY AND THERAPEUTICS. 59
pose of spreading out in a great number of branches, many of
which penetrate into the gums, and thence into thealveohofthe
canines and incisors. While advancing, it gives two branches,
one of which is the orbitary, the other the dental. This last
connects afterwards with the dental passage to furnish the ca-
nines and the incisors into which they penetrate, by the sum-
mit of the root.
The arteries that are distributed to the teeth and lower jaw are
as numerous as those that the internal maxillary furnishes to the
level of the condyle : they spring from the lowerdental. It is well
known that at its birth this artery is forced downwards, then
approximates to the upper orifice of the dental canal, crosses this
canal, accompanied by the nerve of the same name, and having
reached the small molar, divides into two branches, the one men-
tal, which comes from the hole of the chin, the other inci-
sor, that continues its passage and goes under the canine and in-
cisor teeth to disappear in the bone. In advancing, the dental
artery as well as its incisive divisions, furnishes the roots of the
corresponding teeth with dental branches. These branches
penetrate at first into the alveolus, and then into the tooth by the
summit of the tooth.
Finally, the veins of the teeth follow the direction of the arte-
ries ; only the one that comes from the teeth and the lower jaw
has its particular canal under that which protects the artery. As
to the lymphatic vessels, their excessive thinness when they
reach the jaw, prevents us from following them into the teeth,
but there is no doubt that they penetrate the teeth, and join the
nerves, arteries and veins to form the nervous vascular facia,
which constitutes in the canal of the tooth the kernel of its cen-
tral pulp.
Such are the most prominent anatomical characters of the three
principal organs of the dental apparel. Having only seen what
bears upon our speciality, we have passed over many details of
which the application to art by the dentist is not direct, we have
even indicated certain bodies, such as follicles, and the dental
pulp, of which a knowledge is considerably important. We
have reserved them for the next chapter, because a description of
them can only serve to explain the physiological phenomena to
60 ANATOMY, ORTIIOPEDIA,
wrhich this chapter is devoted, and again, because this descrip-
tion is remote from the purpose before us.
Let us, however, observe, before entering upon the subject of
the development of the teeth, that if we were desirous of draw-
ing from the anatomical characters we have assigned to the den-
tal apparel, inductions calculated to designate the sort of food
nature has intended for the constant use of man, we would feel
constrained to admit that it is both vegetable and flesh. But is
there an equal inclination to use the one as the other ? this is a
question authors have differently answered. Some, as Grimaud,*
deducing their opinion rather from the powers that cause the
dental apparel to move, than from the condition itself of the
apparel, compare the strength of the masticating muscles of man
to that of other animals, and believe they are justifiable in con-
cluding that man is fonder of flesh food than vegetable ; they, on
the other side, leaving aside all anatomical appreciation, refer
only to facts, and maintain that as many sects of philosophers,
and many tribes of Indians have completely abstained from
meat, that vegetable food is most proper for our organization.
These opinions are both far firom the truth. Broussonet, con-
sidering that as man has in all thirty -two teeth, twelve of which
are incisors and twelve canine, that belong principally to carniv-
orous animals, whereas the remaining twenty are a more spe-
cial attribute of the vegetable species ; and then estimating
man's disposition for food, divides unequally this tendency for
animal or vegetable food, accordingly, ^f to the inchnation to ani-
mal substances, and |f to that of the vegetable ; so that the
question placed in equation gives for result that the want of
vegetable food is to the desire of animal as 20 is to 12.t
We adopt readily this simple, just and spiritual way of solving
the question, at the same time making all allowance for the
many modifications that climate, habit, and constitution causes
the human system necessarily to undergo.
« Complete Course of Physiology ; Montpellier, 1818.
tSee the new edition of Elements of Physiology, by Richeraud.vol. 1.
PATHOLOGY AND THERAPEUTICS. 61
CHAPTER II.
PHYSIOLOGICAL HISTORY OF THE DENTAL APPARATUS. DEVELOP-
MENT OF THE TEETH, OR DENTITION.
The study of the development of the teeth is truly one of the
most interesting parts of their history. It embraces the descrip-
tion of the phenomena which precede, accompany and follow
it: first, the cutting of the teeth of first dentition; secondly,
that of second dentition. It supposes, necessarily, correct views,
as well upon the development of the follicles and of the bony
portion, as upon the growth and cutting of the teeth. These
different points we shall successively treat of.
Dental Follicles.
We have already said that the teeth are the products of a true
secretion, bearing the same relation to the mucous system as
the various productions are to the skin upon the surface of
which they are observed. Hence they are necessarily preceded
by organs destined for their formation. These organs, equal-
ing the teeth in number, and contained within the jaws, are the
dental follicles.
On examination of the jaws of a foBtus of two or three months
old, we discover that they contain long and deep gutters, divided
into as many cells as there are germs of teeth. This groove is
covered, on its superior surface, by the membrane of the gum,
surmounted by a thin crest, of a fibrous nature, which is called,
by some authors, dental cartilage, but only developed at the al-
veolus ; the fibrous tissue of the gums sends into each alveolus
a prolongation, (alveolo-dental periosteum,) which forms for
each follicle a mucous sac, perforated at the bottom of the socket
through which pass dental vessels and nerves.
It is in this membranous fold which the gum forms, that are
lodged little bodies called follicles or dental germs, representing
round sacs, attached to the gums superiorly, and inferiorly to a
vascular and nervous pedicle, which runs along the bottom of
the alveolar groove. This follicle is formed of one, and not two
62 ANATOMY, ORTHOPEDIA,
membranes, as some modern authors suppose, as Hunter, Blake,*
Bichat, Cuvier and M. Delabarre, who have undoubtedly mis-
taken the alveolo-dental periosteum, or the prolongation of the
gunmiy membrane, for the external membrane of the follicle ;
which makes an essential difference, as we shall soon see.
This single membrane of the follicle represents a closed sac,
and seems to bear the same resemblance to the different papillae,
as the serous membranes do in relation to the organs which they
surround, that is to say, after having covered the gummy fibrous
sac, which lines the alveoli, the follicular membrane is reflected
upon the vessels and nerves which form the pedicle of the pulp,
and appears to be a prolongation of the same. This membrane
is free and smooth upon its internal surface, and adhering ex-
ternally ; it IS generally thin, transparent and very vascular ; its
vessels and nerves are supplied from the pedicle of the dental
follicle and not from the trunks diffused in the mucous membrane.
From the foregoing, we perceive that the dental vessels and
nerves form two distinct systems ; one for the exterior of the
follicle, the other for the part contained in the dental cavity.
The first has its origin immediately from the vascular and ner-
vous system of the buccal membrane, the other supplies special
organs, (as the internal maxillary artery and the trifacial nerve.)
The different pathological conditions of the teeth give daily
proof of the distinction which we have just made, and upon
which anatomists, according to our opinion, have not sufficiently
enlarged.
The true membrane of the follicle encloses a transparent and
viscous liquid, like synovia, containing light flakes, which give
it the consistence of mucilage. It diminishes, in respect to
quantity, from the time of its first appearance until the eruption
of the tooth, at which period it disappears.
The office of the membrane proper is the secretion of the
enamel ; it has only a temporary existence, which is no longer
than the period necessary for the accomphshment of its func-
tions. Blake has treated of it under the name of the caducous
membrane.
This function of the membrane proper has been defined espe-
* Work quoted.
PATHOLOGY AND THERAPEUTICS. 63
cially ill the numerous researches of Herissant. If we carefully
detach, says this learned physiologist, this membrane above the
crown, and examine its interior surface immediately with a
magnifying glass of six or eight millimetres (three to four de-
grees) of focus, we will instantly be struck with admiration at
the appearance of an infinite number of small vesicles, which,
by their transparency, resemble those by which the ice-plant is
covered ; they are arranged in regular rows, one upon another,
and which are, for the most part, parallel with the base of the
tooth.
These vesicles contain at a certain period a very clear and
limpid liquid, which afterwards becomes thick and of a milky
appearance. We cannot mistake the use of this liquid ; it is
evident that when it is spread over the part for which it is des-
tined, and when it has all the necessary consistency, the tooth
will be clothed with a coat of enamel of great brilliancy. Its
irregular productions produce anomalies, of which we have
spoken, and of which we possess many specimens. Messrs.
Rousseau, Desmoulins and Cruveilhier have confirmed by their
own experience the opinion of Herissant upon vesicular pro-'
jections of the free face of the follicular membrane.
The Pulp or Dental Papilla.
We have already said that the membrane of the follicle con-
tains only a transparent fluid, afterwards viscous and then
slighdy yellowish white. But near the third month (of foetal
existence) a little body makes its appearance, which, in the form
of a papilla, rises from the bottom of the socket. This vascular
and nervous papilla becomes gradually more firm, and of greater
dimension. It is at first of a gelatinous consistency, and from
its physical characteristics, bears some analogy to a nervous gan-
glion. Its exterior surface is thin, membranous, and moistened
by a liquid which it imbibes and transudes.
From what we have said of the anatomy of the part, it is diffi-
cult to ascertain precisely from what these little bodies derive
their organization ; the only thing well defined in this respect,
is, that they are formed by the termination and expansion of the
64 ANATOMY, OUTHOPEDIA.
dental nerves and vessels, and that these two organic elements
are here united in equal proportions. They are also the seat of
very energetic, vital action, which creates in these germs the sen-
sitive and living parts of the teeth. A very thin pedicle, formed
by the dental vessels and nerves, is the means of union to that
papilla which is there found suspended like the seed of a grape.
The papilla is necessarily bathed for a time in the liquid which
the sac contains and which diminishes in quantity as the papilla
enlarges. In its more advanced stage the papilla acquires an
increased consistency, elongates, assumes its destined form,
and gradually acquires the volume and form of the future tooth,
of which it is an exact image, and to the secretion of which it
ought to assist. The crown is the part first formed upon the pa-
pilla, for we there find all the depressions and eminences which
the tooth afterwards exhibits.
Development of the Follicles.
We have already shown that the follicular membranes were
of the various rudimentary parts of the tooth, those which
formed the first. We have seen from the beginning, that they
are united in such a manner to the gums, that in exercising a
slight pressure upon the latter that they rise with them, as also
do their vessels and nerves.
But, although the follicles of the apparatus of both dentitions
exists at the same time in the jaws of the foetus, as M. Serres has
correctly proved, these follicles are not formed at the same time
and do not present the same characteristics. About the middle
of the third month of foetal life, we discover upon each half of
the two jaws, four sacs, each of the two anterior and posterior
pulps press against each other, leaving a sufficient space between
the two pairs. The first follicles, which are the smallest, repre-
sent the temporary incisors, the two latter are the temporary mo-
lars. At the end of the third month, in the middle, but some-
what anterior to the space of which we have spoken, there is
seen a marked projection of the external plate of the alveolar
ridge, which contains a fifth sac — it is the canine tooth. These
constitute the complement of the follicles of first dentition.
PATHOLOGY AND THERAPEUTICS. 65
The follicles or germs of second dentition correspond with
the arrangement of teeth already formed, being separated from
them by bony partitions. The following is the relation which
we have discovered these pulps to bear to the follicles of the
teeth of first dentition : first, the follicles of second dentition,
that is the three last molars, are upon the same arch with those
of the milk teeth, but occupying the lateral extremities of it;
second, the follicles of the teeth of replacement, on the con-
trary, are placed precisely in the rear of their corresponding de-
ciduous teeth.
These follicles are at first contained in the same alveoli that
the temporary teeth are ; it is only after a certain lapse of time
that they become gradually separated from them by a bony par-
tition, which, at first fibrous, rises from the bottom of the alveolar
groove, and finally ossifies. A long time, however, after the for-
mation of this bony partition, the temporary and permanent alveoli
communicate by an opening sufficiently large for the passage of a
small cord which joins the two teeth. We shall now show the
order in which the follicles of second dentition appear.
About the end of the fourth month, we discover the sixth sac
at the bottom of the groove of the jaws. This is the sac of the
first permanent molar tooth ; it generally precedes the others sev-
eral months. It is only until about the middle of the seventh
month that we can discover the capsules of the permanent incisors.
At a later period the capsules of the canine and second molar
teeth are developed. With regard to the follicles of the wisdom
teeth, although some authors have pretended to discover them
in the form of ganglions at birth, they are not, however, to be seen
at that period ; we can affirm that this is always the case; more-
ever, in admitting with M. Serres, the existence of the follicles
of the bicuspides or small permanent molars, in the foetus, we
must avow that we have never found them excepting in infants
of eighteen or twenty months old.
Thus far we have been treating upon the organs destined for
the formation of the teeth ; now let us inquire what are the
phenomena of their formation.
66 ANATOMY, ORTHOPEDIA,
Development of Dental Bone.
If physiologists generally at the present day admitted that,
soon after the appearance of the follicle the tooth begins to de-
velope itself in it, that is to say, such as are most precocious,
about the third month of intra-uterine existence, they also agree
that the formation of the teeth takes place in the interior of the
follicle; but they are far from agreeing upon the precise point at
which the first deposite of the bone takes place. Cuvier con-
tends that this takes place between the papilla and the proper
membrane of the follicle which is reflected upon and entirely
surrounds it; others contend, that this deposition of calca-
reous matter takes place within the cavity of the membrane
proper.
Be this as it may, it is the crown of the tooth, particularly
the cuspid part or summit which is first ossified. The pro-
cess of ossification is preceded by a red circle which is situ-
ated around the summit of the papilla; the production of ossific
matter now commences and is the result of a true secretion.
Upon the prominent points which, at a later period, become the
cuspides of the tooth, we observe very fine little scales forming,
which encase the tubercles of the papilla ; these scales, at first
yielding, become gradually stronger, and correspond in number
to the prominences of the dental pulp.
Hence these scales constitute as many points of dental forma-
tion, agreeing with reason, with the number of points of ossifica-
tion of the bone. Thus, for the incisors, there are three points,
according to Hunter ; one, on the other hand, according to Albi-
nus, Blake and Meckel, and the same for the canines ; but the
molars have as many points of ossification as there are promi-
nences upon the pulp.
We have consulted numerous researches to determine this
physiological subject, and we have constantly concluded that
there is but one very small scale for the incisor teeth. This scale,
occupying the fi-ee border of the dental papilla, is always more
prominent in the middle than at the sides ; this fact leads us to
beileve that this might have been the result of the union of
PATHOLOGY AND THERAPEUTICS. 67
three solid points which were organized at the same time. This
appears plausible to us as the free edge of the incisors of children
presents these marked depressions. As to the canines, we never
could discover but one solid scale.
We have always discovered in the small molars, two points
of ossification, each of which assumes the form of that which
characterises the prominence of the crown, or in other words,
it represents a small triangular and pointed pyramid. From
this arrangement, and from the isolation which exists at a cer-
tain period between the various points of ossification at the
crown, we may regard the molars as a reunion of several ca-
nines. Lastly, the large molars are always developed by as
many points of ossification as there are tubercles.
The small scales, of which we have spoken, gradually en-
large — meet each other — unite, and embrace closely the extrem-
ity of the pulp, upon which it forms a case, and represents ex-
ternally its form, so that we cannot detach it without injury,
although the internal surface is as smooth as the external.
When all these little scales are united, we then see the grinding
surface of the crown. The process of solidification takes place
in the inferior jaw before we see any point of ossification in
the superior.
There is one question of importance yet to solve: it is the
formation of the ivory and enamel of the tooth.
There are two opinions upon these points. According to
Jourdain,* Auzebi,t and at a later period Rousseau, the enamel
is secreted before the ivory ; in the meantime, we must acknow-
ledge, that those who entertain the contrary opinion are the most
numerous ; and, moreover, in opposition to these two opinions,
Cuvier says that he has seen the bone and enamel appear nearly
at the same time. Before declaring our manner of accounting
for the formation of these two substances, let us examine, for a
short time, hypotheses, more or less ingenious, which have been
set forth relative to the production of this formation.
* New Elements of Odontologia. Paris, 1736.
t Principles of Odontologia, &c. Lyons, 1772.
68 ANATOMY, ORTHOPEDIA,
Formation of Ivory.
For a long time anatomists entertained the opinion that the
papilla underwent an osseous transformation, and that the ivory
was formed from this by a progressive metamorphosis of its tissue.
The diminution of the size of the papilla in proportion as the
tooth acquires greater thickness, the gradual retraction of the
dental cavity, and its entire obliteration in some old persons,
gives a certain plausibility to that theory which, however, evap-
orates at the moment of its investigation.
Indeed, it is only necessary to examine the rudimentary tooth,
to discover that it is simply placed above the papilla without
adhering at all to its surface, which could not certainly be the
case if the papilla became ossified. Cuvier, and others since
his time, relying upon the analogy of the nail, and its matrix
upon the one hand, and the feather and its papilla on the other
hand, have proved, although after Hunter, that the ivory is
secreted immediately by the dental papilla.
When all the points of ossification, which we have seen sit-
uated upon the surface of the papilla, are united in such a man-
ner as to cover it completely, they present a bony horn, which
gradually extends from the circumference of the vascular and
nervous pedicle, to the point where this pedicle penetrates the
alveolus. The exterior bone being formed, a second is formed
within it, then a third is encased within this last ; thus, in
turns, they are formed. This growth, which is limited to the
period of the complete development of the roots, takes place, as
we perceive, from without inwardly, or from the circumference
to the centre. Once produced, the ivory is no longer subject to
remarkable changes ; its durability depends more upon the ap-
position of the layers upon one another, than upon the modifi-
cation which is produced in its texture.
Formation of Enamel.
The history of the secretion of the enamel is more complicat-
ed than that of the ivory.
It is said that the enamel, like ivory, is the result of the secre-
tion of the pulp, which product oozes through the different
PATHOLOGY AND THERAPEUTICS. 69
layers of the ivory for the purpose of soUdifying upon its surface.
M. Delabarre especially entertains this opinion, which the fol-
lowing phrase will refute. If the enamel is secreted by the
pulp, the disc commencing the ossification which, successively,
should form the crown, will be entirely composed of it ; or this
substance does not exist there still, hence the enamel is not the
production of the pulp.
Other anatomists, as Bertin and Hunter, have contended, that
the enamel is secreted by the membrane proper of the follicle,
which remains in a state of dissolution in the liquid of this fol-
licle until the formation of the crown, and then it forms crystals
upon the internal surface of the crown. Hunter makes use of
an ingenious comparison to demonstrate the crystallization of the
enamel ; he says that it resembles the deposits of salt of urine
deposited upon bodies found in the bladder.
That opinion is not absolutely incontestable ; nevertheless, it
seems generally admitted at the present day. Cuvier entertains
this opinion, with this difference only, that the enamel instead
of being deposited immediately upon the crown, forms upon the
portion of the internal face of the follicle which covers the crown.
In this manner he accounts for the greyish line which always
exists, as we have stated in the anatomical part of this work,
between the ivory and enamel, and which is nothing more than
this seared leaf between these two substances.
The enamel is soft and of a cartilaginous consistency at the
time of its formation ; it is of a dull white and is distributed in
drops, which are at first spread upon the first layers of the ivory,
afterwards upon the succeeding layers. In the foetus we can
separate it easily from the bony matter ; we then discover that it
is thicker upon the prominences of the crown than in other
parts, and it becomes extremely thin as it approaches the neck
of the tooth. Hence, the deposition of enamel takes place in
an opposite direction from the ivory, in other words it is deposi-
ted from within outwardly. Its secretion is only temporary ; it
is limited to the existence and to the functions of the membrane
proper, and is necessary only to the production of the crown.
In admitting the theories of which we have spoken in regard
to the formation of the ivory and enamel, it still remains to be
70
ANATOMY, ORTHOPEDIA,
explained why the crown is the only part which is covered with
enamel. Herissant is the only one, as we have already seen,
who has suggested the means of solving this very difficult ques-
tion, by stating that the part of the follicle corresponding to the
crown, was furnished with glandules, Avhose functions were to
secrete the enamel.
We should in truth say, that wishing to convince ourselves of
this fact, we have several times discovered upon the surface of
the leaf of the membrane proper, as far as the top of the crown,
a kind of pulp resembling little white molicular globules.
These little bodies were very few in number, nearly impercepti-
ble and atrophoid when the enamel had been developed and
was visible, while their number and size may be perfectly dis-
tinguished in those cases where the production of enamel had
not yet commenced. We lay great stress upon this point, since
it leads to the solution of this problem which has called forth
so many theories, to wit : how does it happen that the enamel
substance is deposited exclusively upon the crown.
Indeed, when the crown of the tooth is once covered with a
layer of enamel, the leaf of the membrane, or at a later period the
little corpuscles are atrophoid. It is then evident that the root,
the development of which is later than that of the crown, has
nothing in it in common with the enamel.
That opinion, which appears to us most reasonable, is still
supported by the fact, that the teeth of animals which have not
the follicular membrane are not covered with enamel ; while in
those, on the other hand, in which this membrane exists after
the eruption of the teeth, the secretion of enamel continues after
this eruption, as that of ivory. The incisive teeth of the rabbit,
beaver, rat and other gnawing animals, are in this latter case, as
we shall soon see in speaking of the growth of teeth.
In the meantime, we perceive from what we have already said
upon the phenomena of the formation of the teeth before their
eruption, that we can deduce the following consequences.
Of the two constituent parts of the tooth, to wit : the cortical
or hard portion, and the pulp or medullary portion, this last is
first developed ; and of the two distinct elements of the hard
portion, the ivory and enamel, the ivory is first formed.
PATHOLOGY AND THERAPEUTICS. 71
The formation of the cortical substance of the tooth com-
mences at the crown ; the roots are afterwards formed.
The pulp or papilla finding itself as it were enclosed in the
midst of solid matter, in the formation of which it assists as
much of itself as by its follicular membrane, and which gradu-
ally contracts its cavity, diminishes continually in size and
finally entirely disappears.
In other respects we should frankly acknowledge that if mod-
erns had prescribed facts upon which rests the theory of the
development of the dental bone, they have found among the an-
cients the basis of that theory perfectly established. There are
abundant proofs of this assertion. We content ourselves with
the following one, extracted and translated from a German anat-
omist,* who wrote two hundred and fifty years ago, a period
when anatomy was first brought to light : "The teeth are formed
from a species of mucus, enclosed in the cavity of a follicle,
they are developed like a rudimentary body, around which an
incrustation is formed, differing in that respect (longe diversce)
from the formation of bone, which is effected through the medium
of a cartilage (per intercessionem cartilaginuni,) &c. &c."
THE GROWTH AND ERUPTION OF TEETH IN GENERAL.
Tfie Growth. — When the bony covering is once formed
around the pulp and envelopes it entirely, we may then soon see
new layers under those first formed. These layers are at first
more and more extended, in proportion as they are more distant
from the period when the tooth first began to develope itself
At a later period they present an inverse tendency; they are en-
cased in the preceding ones ; they gradually raise them and push
them from the pulp, which they soon embrace from the circum-
ference to the base. The crown is now completely formed ; the
enamel is deposited upon it as has been already stated ; and the
process of evolution, after having undergone a delay, according
to some authors, the process is renewed. New layers of ivory,
products of the pulp, embrace it inferiorly, forming successive
caps which by degrees encase each other; they surround its
pedicle, descend as far as its extremity and form the root.
* Valcherus Coiten, cotemporain de Visale.
72 ANATOMY, ORTHOPEDIA,
To depart from this epoch, says M. Blandiii, the tootli has
completed its growth in length ; the bony layers which succeed
can then no longer increase its bulk, and as it is always by an
interior juxta- position that this growth takes place, the dental
cavity gradually contracts, the pulp diminishes, and the circu-
lation being confined in its vessels, its secretion abates and soon
entirely ceases.
Here are limited the changes which the single rooted teeth
undergo ; but, the mechanism of such as have several roots is
more complicated. Their ossification commences, as we have
already said, in several points, representing as many little caps
as the tooth has prominences or tuberosities upon its summit,
and as the pulp presents elongations ; for, in examining the in-
ferior part of a germ, we perceive that the vessels which pene-
trate it are divided into two, three or four bundles, according as
it is destined to form two, three or four roots. Blake and Fox,*
ignorant of this fact, describe upon the pulp, bony angles,
which divide the base of the crown into as many segments as
it ought to have roots.
These caps are naturally convergent at their base ; each in-
creases at its side, by the addition of successive layers increas-
ing as they approach the base. They soon meet each other, and
all at once unite, those that are without with those that are within;
firom this time they form upon the superior part of the papilla
only one great cap, undulated upon its surface, and the growth
of which continues the same as if it was primitively developed
at the same point. Finally, when the ossiform stock of the tooth
has reached the union of the papilla with its pedicles, the cal-
careous matter is secreted at once around the body of the pa-
pilla and its pedicles ; it encompasses each of them with a tubu-
lous envelope, continues with this from the rest of the pa-
pilla, and the growth progresses finally as in cases of one point,
with this difference only, that the osseous layers, instead of pre-
senting a series of simple cones, are subdivided into as many
additional hollow cones as the tooth should have roots.
"Thus, (continues M. Blandin, from whose work we have
quoted,) the teeth increase from the summit of the crown to the
* Remarks upon Dentition ; Guy's Hospital, London,
PATHOLOGY AND THERAPEUTICS. 73
end of the root, and from the exterior inwardly; it is at once
completed in length and thickness, by moulding itself upon the
papilla, and embracing it accurately at every point."
Here arises another very important question : why is the
growth of teeth in general, and especially those of man, con-
fined to narrow and very limited spaces ; or, in other words,
what is it that impedes the growth of teeth ? For the solution
of this question, it is only necessary to recollect that the forma-
tion of ossiform substances being subordinate to the presence of
the papilla, and that the growth of the ivory being effected in
concentric layers, that is to say, from without inwardly, that the
pulp, surrounded on all sides, and gradually constrained by
them, it is necessarily more and more restricted, and in such a
degree that its functions become arrested all at once, under the
last long layers which it has removed. The growth of the tooth
is now entirely completed. ,
That limited growth of the human teeth, whatever Fallopius
may have said, and others since his time, who believed that
they might have an indefinite increase, has been long since an
incontestable fact noted by anatomists ; but no one that we know
of has ever before given a satisfactory explanation of it, not M.
Oudet, as has been generally supposed, and as M. Blandin* has
erroneously asserted ; but before Dr. Francis Lavagna, of the
Imperial Academy of Genoa, who, in a work published in 1812,
consequently eleven years anterior to the memoir of M. Oudet,
has demonstrated that it is exclusively to the pediculated form
of the dental papilla that the human teeth should embrace that
part entirely, gradually press upon it, then to destroy it by its
pressure, and hence to arrest of itself its growth in length, by the
death of the principal agent of vitality which the teeth possess.
Thus the incisors of the rongeurs, as the beaver, the hare, the
rabbit, the rat, and so on, which possess the faculty of continu-
ally growing, and even to be reproduced after being broken, as
the following phrase, printed more than two hundred years,
proves : " Quod si acutis forcipibus secaniur, una tantium node
renascuniur.^'-f I'hus the incisors of the rongeurs present a pa-
* Work previously quoted^ page 101.
tMathiolCj Latin edition oi I67ij page 299.
10
74 ANATOMY, ORTHOPEDIA,
pilla, in conformation perfectly the reverse of that of the human
teeth. That papilla is indeed unprovided with a pedicle ; it is
conical, and supported at the bottom of its follicle and the alveo-
lus which encloses it, by the base of the cone which it repre-
sents. In this way it can continually secrete calcareous layers,
without ever being embraced by the osseous walls of the dental
canal, at the part whence it receives its vessels and nerves.
As we do not wish you to think that, by depriving M. Oudet
of all the merit of the new idea which is the subject of his me-
moir upon the dentition of rongeurs^ we cannot be deceived by
the simple appearance of identity between his views and those
of Dr. Lavagna, we will quote what this last writer says :* "The
incisor teeth oi rongeurs, at least those of the wolf, the hogs of
India, and the mice that I have examined, are of the same thick-
ness through their extent, and in this respect they are very dif-
ferent from the teeth of man, which have pointed roots. The
cavity of the teeth of rongeurs differs still more from ours;
from the body of the tooth to the extremity of the root, this cavi-
ty gradually enlarges in such a manner that the teeth, even in
their roots, present a large cavity. * * * * This large cavity in
the roots of the teeth must leave a free access to a great number
of vessels, which, distributed through the substance of the
tooth, must render it very compact and resisting. * * * * The
teeth of man have, on the contrary, in their roots, so small a
cavity, {unforame sipicciolo,) that blood-vessels, as it were in-
visible, can scarcely penetrate it, etc. etc."
Writers generally have been so much at a loss to explain the
growth of the human teeth and those of the inferior animals
which are analogous to these, and to account for the constant pro-
longation and reproduction of the teeth of rongeurs, that they
are content with the explanation of Lavagna, repeated by M.
Oudet ; but, in our opinion, the following question should have
been put :
1. How is it that the occlusion of the hole of the roots of the
* His work is entitled, Esperienze e rijkssioni sopra la carie rfe' denti
umayii coW ag^unta di un nuovo saggio su la riproduzione dei denti negli ani-
malirosicanti. The phrases quote* are extracts from pages 161 and 163.
PATHOLOGY AND THERAPEUTICS. 75
human teeth should cease and leave an opening only just large
enough for the passage of the nerves and vessels ? 2. How does
it happen that in man, the teeth, after they have ceased to grow,
their interior cavity does not only still exist, but that the hole
at the extremity of their root does still exist? 3. Finally, how
does it happen that the cavity of a tooth which is exposed, be-
comes closed by the deposition of osseous matter, which would
appear impossible if the functions of the pulp had entirely
ceased? The foregoing remarks do not, assuredly, prevent us
from adopting the explanation which we have already given —
in the impossibility of which, we will substitute in the place of
it another more reasonable.
Thus, what we know of the manner by which the growth of
the calcareous portion of the teeth is effected, we are obliged to
admit that it takes place by a simple juxta-position, and not by
intus-susception, as is the case with other bones. The experi-
ments of Hunter upon the nutrition of young animals with
madder, establish these facts, since the teeth become red on the
part that is forming during the time the animal is fed with this
article.* Various pathological facts also prove this mode of
growth, as we shall see when treating of the diseases of the
dental follicles. We very often observe, indeed, upon the
crowns of the teeth of certain individuals, prominent undula-
ting transverse lines ; sometimes we observe rough grooves or
deep pits, which are nothing more than the effects of disease
under which such individuals were laboring when children.
They affect the whole bony structure of the tooth, as well as
the enamel.f
We shall now bring our remarks upon the development and
increase of the teeth to a close, by treating of the order which
they follow in their solidification.
* This fact, however, has been recently contested by M. Fiourens, secre-
tary of the Academy of Sciences, who has shown that it is not only the part
of the tooth whose formation is going on becomes colored when fed upon
madder, but also such parts as had been previously formed. This necessa-
rily presupposes a more complicated or more vital process than that of sim-
ple juxta-position.
jThis is sometimes, but not always, the case, for it often happens that the
enamel ia the only part which sustains a direct or immediate injury. — Trans.
76 ANATOMY, ORTIIOPEDIA,
This process proceeds in the same manner as do the develop-
ment of the folUcles. The appearance of the first points is seen
in the foBtus, between the fonrth and fifth months, beginning
with the central incisors, and those in the lower sooner than
those in the upper jaw ; the lateral incisors, and then the ante-
rior molars are the next. At a later period these points appear
upon the canines, and then upon the second small molars.
The solidification of the permanent teeth commences during
the last month of gestation, in a small point upon the anterior
and external tubercle of the first large molar. Sometimes, before
the term of fcctal existence, there are three or four isolated points
in place of the one just mentioned, which unite at the close of
the first year. After the first large molar, the central incisor
becomes ossified during the month after birth. Two months
after this, the follicle of the lateral incisor is covered with a
small scale ; then, about the sixth or seventh month, the canine
is discovered to be ossifying. It is not until about the third or
fourth year that the formation of the bicuspides commences :
these are followed by the second large molars. As to the third
molar, or wisdom tooth, we have rarely seen it formed before
between the ninth and tenth years. The following is the man-
ner in which the teeth arc cut.
The Eruption of the Teeth in General.
At birth, the temporary teeth, enclosed in the socket, present
the following appearance : The crown of the middle inferior
incisor is nearly completed ; the superior is a little more tardy.
The lateral incisor is later, especially that of the superior jaw.
After these, the small anterior molars, the various isolated parts
of the crown of these are now united ; this gives them a large
size, though they have not at this time acquired their full
height. As for the canine and small posterior molars, the first
of these present only the extremity of its crown, the second has
the most of its parts separated from each other, and connected
only by a very thin pedicle.
During the development of the teeth, changes are going on in
the jaws ; the partitions which separate the follicles are com-
PATHOLOGY AND THERAPEUTICS. 77
pleted ; the alveoli form and accurately mould themselves to the
teeth ; finally, the maxillary bones acquire volume in every
part. The inferior jaw offers this exception, instead of having
only one canal, it is traversed by two, which sometimes have
each of their openings partially bifurcated ; at other times only
one ; each of these canals contains an artery, one belonging to
the teeth of first, the other to those of second dentition. The
superior, if perceivable at the time of birth, gradually diminishes,
and soon leaves only the vestige of its first existence ; the infe-
rior continues through life.
Be that as it may, it is no less true that if, at the time of birth,
the teeth are very much developed, they still remain closed in
the alveoli, and covered by the gums. Pliny, Columbus, Van-
swieten, Donatus, Haller,* Soemmering and Bandelocquef of
later date, quote many examples of children who have been
born with teeth, (all the world know that such was the case
with Louis XIV and Mirabeau ;) but these are only exceptions,
and it is well known that it is very rare for one or two teeth to
be cut at birth.
The presence of teeth is perfectly useless to a child while it
derives its nourishment from its mother, still the jaws need a
certain firmness to support the efforts of sucking ; nature, like-
wise, attentive to all the necessities which has nothing super-
fluous, has furnished both the alveolar borders, which are after-
wards to be occupied with teeth, with a cartilaginous substance
which we know has been called by many authors dental carti-
lage, and which diminishes as the eruption of the teeth ap-
proaches, and entirely disappears after they have come through.
But the child, a few months after its birth, not finding in milk,
nourishment proportioned to its wants, and consequently being
compelled to have recourse to more solid and more abundant
food, it becomes indispensably necessary that at this time its
maxillary apparel should be fortified with proper instruments for
separating and chewing its aliment. This results from the ap-
*This learned physiologist mentionSj in his Elements of Physiology, nine-
teen cases ot children born with teeth,
t Traite d'A^couchements.
78 ANATOMY, ORTHOPEDIA,
pearance of the teeth externally, which were before contained in
the alveoli.
While these organs are developing and their roots increasing
in length, the crown, yielding to a vital motion which forces the
tooth outwardly, progresses in its alveolar cavity, removes from
its bony partition, and reaching shortly the gum, appears through
its tissue.
But what is the cause of this singular phenomena, true action
of locomotion, in virtue of which the teeth advance in their
alveoli, and removing the obstacles which oppose their egress,
terminate by removing the enclosure in which they were en-
veloped? In a word, how and why do the teeth daily penetrate
through the gum? A question assuredly simple, but the solu-
tion of which, however, has long since become an arena, upon
which the makers of hypotheses have exercised a show, against
which the sagacity of the most profound physiologists have
fallen.
Some have thought that the eruption of the teeth could be ex-
plained by the pulsation of the arteries, others have believed
that they could account for it by a struggling which exists be-
tween the vital force of the teeth and that of the gums, a strug-
gling which would result to the advantage of the first ; others
again attribute this phenomena to the contraction of the alveoli.
As neither of these three hypotheses can stand the test of a crit-
ical examination, we have sought for a better explanation ; it has
also been said, that if the teeth pierce the gums, it is because
their roots, in proportion as they elongate, press upon the bot-
tom of the alveoli, which presents to them a firm resistance,
forces the tooth through the gum, which, more yielding than the
base of the socket, gives way to the efforts which the crown ex-
erts against its interior parts, spreads itself, finally ruptures and
permits the tooth to escape. This explanation has, at least, the
merit of extreme simplicity ; it has also deceived many phy-
siologists; but we, who know that the membrane which lines
the base of the alveoli is by far more sensitive, and consequently
by far more irritable than the tissue of the gums, and moreover,
incapable of offering the support necessary to the progression of
the tooth, we are forced wholly to reject. «
PATHOLOGY AND THERAPEUTICS. 79
This assertion has something in it similar to that of those
who admit that the eruption of the teeth is effected by the ap-
proximation of the alveolar walls and the elevation of the floor
of the alveoli ; but this opinion is inadmissible, for the reason
that the alveoli, on the one hand, narrow themselves transversely,
and that on the other, they become deeper, as the teeth develope
themselves.
M. Delabarre, moved without doubt by the desire, assuredly a
praiseworthy one, of explaining the eruption of these organs by
the laws which govern the other functions, has, so to speak, as-
similated this phenomena to that of parturition, in declaring that
the tooth forces itself out by the contraction of the internal mem-
brane attached to its neck, as we know, a neck which is drawn
towards the surface of the gum, and which, arriving there, can
go no farther, because the contractile force of the membrane is
exhausted.
This theory is assuredly very ingenious, but difficult to sus-
tain, in truth, how can we suppose this excessively delicate
membrane, which lines the follicle, is sufficiently powerful to
force out a body like that of a tooth ?
Little satisfied with the explanation of M. Delabarre, Lemaire,
who in all things aims at originality, pretends that when the
body of the tooth is formed, the vessels which penetrate its cavi-
ty, being no longer charged with furnishing it with calcareous
matter, take a new action and greater energy, whilst those which
belong to the gum, carrying life to the capsule, become useless
and obliterated ; then the body of the tooth, by the energy of its
vessels and nerves, elevates itself in its alveolus, whose orifice
distends to give' it a free passage ; the roots form progressively ;
the crown finds itself in immediate contact with the gum ; this
latter permits itself to be penetrated, absorbed, and then passes
through it without any other aid than the extensibility of the
one and the contractility of the other.
There are two objections to the theory of Lemaire ; first, it
will be committing an anatomical error to suppose that the bor-
ders of the alveoli enlarge of themselves for the purpose of open-
ing a passage to the teeth : another objection is that the alveoli
always show openings sufficiently large for the escape of the
80 ANATOMY, ORTIIOPEDIA,
teeth ; second, nothing proves that the vessels and nerves of the
teeth at the time of their eruption have acquired an energy dif-
ferent from that which corresponds to the general progress of the
whole economy. Whatever this energy may be, it explains
only with difficulty the movement of the ascension of the infe-
rior and the descension of the superior teeth.
Finally, M. Serres, fearing, doubtless, to add an hypothesis to
those of his predecessors, contents himself with explaining the
fact, by the fact itself, and he considers it as the result of apri-
mordial laio, analogous to that, in virtue of which the testicle
passes, in the required time, from the abdominal region in the
scrotum, or to that to which the foetus obeys, when it breaks the
envelopes which holds it to the uterus.
As prudent as M. Serres, perhaps more fortunate than him-
self, we content ourselves by saying that the opinion which ap-
pears to us the most plausible, and which is altogether con-
firmed by observation, is that which explains the cause of the
passage of the teeth from their alveoli in the progress of their
growth; in other words, that the teeth depart from the alveoli
because these last can no longer contain them, and if they reach
the level of the socket sooner than its base, it is that they are
drawn thither even by the tendency of the internal membrane
of their sacs which envelope them, and which, from the gummy
membrane, connects itself to the neck of the tooth, to which it
strongly adheres. That cause is not assuredly unique, it exists
at other parts of the gum, which is far from being foreign to that
organic action ; in such a manner that at the same time that the
tooth is forced to escape from the alveolus, it is effecting, in the
interior of the gum, a process by which a way is prepared for
its passage.
In the actual state of the science, it is not easy to say if that
outlet exists before the eruption of the teeth, or if it is formed at
the time of their eruption. Physiologists do not agree upon this
point. Some, among whom are Blandin, otherwise inclined, as
also M. J. Cloquet, has made a concession to an opposite opin-
ion, viz. "the young tissue being raised, the mucous tissue
swells, reddens, inflames and becomes painful ; it very soon
becomes white, one or more openings appear upon its surface,
PATHOLOGY AND THERAPEUTICS. 81
according as the crown is iurnished with one or more tubercles,
and these last appear outwardly, in the first case, after having
simply dilated the simple opening which is prepared for it ; in
the second, after having ruptured the diiferent parts which sepa-
rate all these special openings, converting them into one.* That
opinion, as can be plainly seen, gives us sufficient latitude to ex-
plain the diseases generally attributed to dentition.
Other physiologists, on the contrary, at the head of whom is
M. Delabarre, contend that the opening through which the tooth
passes is not the result of an ulceration of the gum, but of the
neck itself, dilated from its follicle, in such a manner that the
opening, once effected, need not be enlarged. This opinion,
repeated by M. Herissant, who says, the permanent gums are
neither torn nor pierced by the teeth which pass through them, as
has been supposed ; this opinion, we say, which leads to the
conclusion of an iter dentis, has nothing which offends, when
we think how great, under all circumstances, is the foresight of
nature, as it is also generally admitted ; besides, it is another
proof to those who believe that the diseases which often attack
infancy, during the eruption of teeth, are altogether strangers
to it.
Eruption of the Teeth of First Dentition.
The period at which the teeth of first dentition appear is va-
riable. There are examples, as we have before said, of children
having one or more teeth at birth ; there are other examples,
also, in which they have not cut any of their teeth for one, two,
three or more years, and still be in perfect health, as Alphonso
Leory has stated.f Vanswieten reports a case of a child, very
vigorous and healthy, who had not cut a tooth until she was
nineteen months old.| Charles Raiger has made mention of a
child, whose four canine teeth did not appear until the thirteenth
year.|| We also find, in Maury's work, a similar case of a young
girl, seven years of age, who had not cut the two central inferior
*See the Memoirs of M. Blandin, page 110.
t Traite de Medicine Maternelle.
f Comment, in Aphor., tom. 4.
II Collection Academique, partie etranger, torn. 1.
11
82 ANATOMY, ORTHOPEDIA,
incisors. We ourselves have met with several cases of tardy
dentition.
We may, however, generally say, that the temporary teeth ap-
pear from the sixth to the eighth year after birth, rarely sooner
but sometimes later. The order in which they appear through
the gums is the same that follow in their development, and are
Uable to like variations. Thus, from the sixth to the eighth
month, the inferior central incisors appear ; the superior follow
these ; one or two months later the lateral incisors follow the
same order. At the twelfth or fourteenth month the small mo-
lars appear; sometimes, however, the canines appear at this
time ; finally, the second small molars complete, about the age
of two years, or two and a half, first dentition. We again repeat
that the eruption of the teeth does not always follow the order
which we described, and whoever will observe this process of
nature, (a phenomenon as important as it is complicated with
the organism,) upon a certain number of infants, will be aston-
ished at the diversity he will meet with. Below we give a table
of the usual periods at which the teeth appear.
From 6 to 8 months, the 4 central incisors.
" 7 " 10 do. " 4 lateral incisors.
" 12 " 15 do. " 4 small anterior molars.
" 15 " 20 do. " 4 canines.
" 20 " 30 do. " 4 small posterior molars.
Total, 20 temporary teeth.
We have adopted, as will be seen, the opinion of M. Serres,
who admits, in opposition to the order established by Sabatier,
Bichat, Boyer, and the most distinguished anatomists who have
preceded him, that the canines do not appear until a few months
after the eruption of the small anterior molars. We adopt it as
a common consequence of a law of the organization, which we
have always been forced to acknowledge, that at all stages the
canine are not developed so soon as the first small molar. In
justice to the celebrated Scotch dentist, Blake, it is necessary to
state that M. Serres has only copied the opinions of this distin-
guished writer, whose views we have frequently quoted, and
who, twenty years previously to the publication of the work of
PATHOLOGY AND THERAPEUTICS. 83
the latter, said, "On examination of the teeth of a number of
children at birth, I discover in both jaws that the crowns of the
central incisors are perfect ; that those of the lateral and the an-
terior molars are far advanced, and that the canines and poste-
rior molars were but slightly developed."
Blake and Serres content themselves by stating this fact;
perhaps, if they had explained it by saying that the office of the
canine teeth was to tear, and that it required the assistance of
the hands, nature had not seen fit to develope these teeth before
the hands were capable of assisting them.
When the crown has entirely passed through the orifice of
the alveolus, the gum which is united by its fibrous portion to
the external roots, under the name of alveolo-dental periosteum,
adheres around the neck of the tooth, which it closely embraces.
The maxillary bones at the same time undergo great changes ;
their alveoli, which had been distended by the crowns of the
teeth which they contained, afterwards contract and adapt them-
selves accurately to the roots ; this brings about an entire change
in the physiognomy of the child.
The milk teeth then continue to increase ; their roots, at first
hollow and short, become filled up, elongated, and there is a
time during which they are shed and replaced by others. But
before speaking of these phenomena, let us examine the organs
which, in the jaws, are opposed to them, and which nature has
prepared for replacing them.
We have said above, and anatomical researches have suffi-
ciently demonstrated, at the term of gestation we distinctly dis-
cover follicles of the incisors, and even of the secondary canine
teeth. They are placed in as many alveoli, in the rear (but
very deep) of the capsules of the corresponding temporary teeth,
from which they are separated by a fibrous partition, the exis-
tence of which has been denied by Meckel, on account of its
great thinness. But, in proportion as the milk teeth grow, and
especially when they have passed through the orifice of the
gum, carrying, in its progressive movement, the alveolar pro-
cesses, it gradually becomes more distant from the follicles
which then appear to sink themselves; the extremity of the
capsules, which is immediately connected to the gum, lengthens
84 ANATOMY, ORTHOPEDIA.
out, and forms as many little prolongations, which afterwards
being enveloped by the progress of ossification, is found con-
tained each in a little canal.
These are the prolongations already described by Fallopius
and Eustachius, and verified by Albinus, Blake and Meckel, to
to which M. Serres has given the ndivae o{ gubernaculum dentis,
wishing thus to express the use to which they were intended.
But we will observe, that if they had this office, the teeth of
second dentition would always have pierced the place where
these canals terminate ; but this is far from being the case in
the incisors, it is rarely seen in the canines, and never in the
molars. Some authors look upon these appendices simply as a
kind of elongation of lines of continuity which unite the folli-
cles of the second teeth to the gums ; and as to the osseous ca-
nals in which they are lodged, as in cases they would be, ac-
cording to these authors, the necessary result of the ossification
of the parts which they traverse. In other respects, these pro-
longations, an attentive examination of which permits us to
prove the existence of the cavity, are in number equal to
those of the follicles of the secondary teeth, which alone are pro
vided with them.
When the child has arrived at the age of six or seven years,
the permanent teeth are nearly completely developed. The
central and also the lateral incisors have already grown slightly
near the roots ; the crown of the small molars, and those of the
canines, are nearly complete. Each jaw contains, at this time,
twentij-six teeth, ten temporary, ten of replacement, and six per-
manentjwhich are the six large molars, the eruption of which,
for the four first, generally takes place about the seventh
year, and always precedes the loss and replacement of the milk
teeth. All these teeth are lodged in a certain number of alveoli,
divided in three apartments, the anterior or smaller of these be-
longs to the teeth of double dentition, and the posterior to the
permanent, which are succeeded by no others. The partition
marks the limits of these apartments, which separates, on each
side, the first large molar from the posterior deciduous molar.
Things are then so arranged that the permanent teeth, that is
to say, the large molars, are placed upon a line of the arch occu-
PATHOLOGY AND THERAPEUTICS. 85
pied by the temporary teeth, which assists in the continuation
of the curve posteriorly. As to the teeth of replacement, they
present the following arrangement: the incisors and canines
are placed in the rear of the roots of the corresponding tempora-
ry teeth ; the bicuspides below the deciduous molars in the infe-
rior, and above them in the superior jaw. By this arrangement,
the first and second large molars, which solely occupy all the
external apartment, are very slightly lodged here ; thus there is
reserved for the bicuspides a part of the interior of the jaws oc-
cupied by the deciduous milk teeth.
The incisors and the canines have been, under the relation
of replacement, not as conveniently situated as the molars ;
they are at first considerably larger than their corresponding
temporary teeth ; afterwards, they occupy posteriorly a smaller
circle in the arch ; this causes them to be pressed against each
other, so that the alveoli of the four incisors of replacement oc-
cupy as much space as do those of the deciduous canine and
incisor teeth. It also occurs, from this arrangement, that the
canine teeth of replacement, not having sufficient space by the
side of the incisors, are deeply imbedded exteriorly in the infe-
rior jaw, and in front of the lateral incisors, whilst the superior
incisors occupy, far from the alveolar border, a narrow space
which is reserved for them at the base of the apophysis of the
superior maxillary.
Finally, when the teeth of replacement have acquired their
full size, which happens about the seventh year, it only waits
for a suitable time to break the barrier which the gum oifers to
them, and to rise from the socket. But before this eruption can
take place, the milk teeth should give way for them. It is this
process which we shall now treat of.
Shedding of the Milk or Temporary Teeth.
We shall now treat of that which generally takes place about
the seventh year of age, as the teeth of first dentition are shed
and those of the second commence to appear. The order in
which the milk teeth appear is always such as is observed in
their shedding. Unhappily, in this circumstance, as in many
8G ANATOMY, ORTHOPEDIA,
Others, nature wishes to conceal from us the laws by which she
controls her operations. Let us, in the meantime, endeavor to
penetrate these views, by explaining, if it is possible, the phe-
nomena which accompany this shedding.
Thus, as we know, each jaw presents, in infancy, two series
of parallel alveoli. The anterior series is destined to receive the
milk teeth, the posterior encloses those of replacement, so that
if the first teeth are not shed before the eruption of the teeth of
second dentition, each jaw would be furnished with two rows
of teeth : a circumstance very rare, but which, however, has
happened.
The first effect of the movement of progression of the second
teeth is the pushing or forcibly removing the obstacles which
they meet in their course, and which at first consists in the
alveolar partitions separating the two classes of teeth. But this
obstacle being removed, the roots of the milk teeth experience
the pressure ; this pressure, gradually increasing, contracts the
vessels and nerves of these teeth, and finally cuts off their vi-
tality. The fluids of which the milk teeth are thus deprived,
are carried in abundance to the matrices of second dentition,
and augment the eruptive force of the teeth of that class.
This method of explaining the shedding of the milk teeth by
the mechanical destruction of their alveolar partitions, the com-
pression of their nutrient vessels, and the destruction of their
roots, is far from being above all doubt, at first, because it can-
not be applied to the very frequent cases in which the teeth are
shed without having been in contact with those that are to re-
place them ; in the second place, because they do not show why
these teeth, which have ceased to exist before their shedding,
are not shed before having lost a part, sometimes even the whole
of their roots. It is, then, necessary to add another cause of the
change of these teeth to those of which we have spoken, and
that cause, which we have believed resided in a particular work
of absorption, whose existence we have admitted with M. Dela-
barre,* who, however, found concerning it some very clear ideas
expressed by Soemmering, and developed by Bichat himself
* Treatise upon Second Dentition.
PATHOLOGY AND THERAPEUTICS. 87
Thus, whether the milk teeth, becoming foreign bodies,
cause irritation, or whether the development of the permanent
teeth contributes to a more active inflammatory action, it is cer-
tain that the vitality of these parts and consequently the energy
of their absorbent functions, are always considerably increased.
This results from the destruction or rather absorption of the
phosphate and carbonate of lime which enter into the composi-
tion of the roots of the milk teeth. This kind of wasting away
ordinarily commences at the extremity of the roots, which be-
come unequal, rough, and gradually disappear; it is not effect-
ed, as some other organs subject to like destruction, at the ex-
pense of all the exterior or deep molecules of which they are
composed ; all this commences at the surface, and proceeds from
the circumference to the centre; but the enamel always resists,
except towards the internal part of the crown, where it has
been observed to be sometimes eroded.
This mechanism is the same for all milk teeth ; but the de-
struction of the alveolar ridges takes place differently around dif-
ferent teeth. Around the incisors and canines the ridge is de-
stroyed perpendicularly, but around the molars the process is
more difficult, for the reason that their roots diverge to the right
and left in the jaw, more especially in the superior. This work
of destruction commences here on a level with the alveolar bor-
der, from thence it goes on ; the ridge of porous tissue between
the roots is the last destroyed, upon the phenomena of which
we shall soon treat.
Such is the mechanism of the shedding of the temporary
teeth ; the explanation which we have given of it is simple, and
in conformity to the laws of our organization. This loss of the
temporary precedes the eruption of the permanent teeth, of
which we shall presently treat. These two phenomena are so
connected, the one with the other, that children who lose their
first teeth prematurely, are those whose second teeth are the
most precocious.
Eruption of the Teeth of Second Dentition.
We shall now see how the shedding of the teeth of first den-
tition is effected, and treat of their immediate replacement by
88 ANATOMY, ORTHOPEDIA,
Other organs. This process is subject to great variations ; for,
indeed, we often find that the destruction of the roots of the milk
teeth progresses so slowly that these organs maintain their posi-
tions and impede the progress of the temporary teeth ; on the
other hand, from some unknown cause, the replacement of the
teeth does not occur until a very long time after the moulting of
the milk teeth.
We find, in the General Archives of Medicine* the example
ofa woman, aged forty-three years, who had her four incisor
teeth posterior to the four deciduous incisors. A year later, the
four molars, which until this period were wanting, showed
themselves. Her parents said that she yet had milk teeth. We
know of several similar cases.
After the seventh year, at which period there are twenty teeth
situated in the whole extent of the alveolar arches, between the
maxillary tuberosities above, and the coronoid apophyses below,
these arches ought to receive successively the second teeth
which replace an equal number of temporary, and posterior to
these are added three new organs in each side of both jaws.
But how do the maxillary bones adapt themselves to the arrange-
ment of all these productions? How do the teeth arrange
themselves in a line upon the alveolar borders, without impeding
each other in their course, without turning each other from their
route, without usurping the place of each other? Let us en-
deavor to unravel this intricate question, whose solution is far
from being unimportant.
At first the development of the maxillary bones does not go
on simultaneously and in a continued manner upon every part
of their extent, as we observe in the other parts of the osseous
system. The cause of this difference is that these bones pre-
sent in their composition two substances essentially distinct, as
much by the manner in which each one developes itself, as by
the ulterior metamorphosis that they undergo. Concerning
these two substances, the one belonging to the general osseous
system, forms and regulates itself according to the laws which
regulate the other bones ; it comprises nearly the whole of the
* June number, 1840.
PATHOLOGY AND THERAPEUTICS. 89
jaws, or rather it forms, truly and properly speaking, the maxil-
lary bones ; the other constitutes the border or alveolar process.
Although this last may be equally osseous and lasting as the first,
it forms not an essential part of it, and is, as it has been plainly
said, only a phenomenon of dentition ; it appears in the same
time with the organs which produce the teeth, it is developed
with these last, moulds itself upon their external forms, follows
their direction, undergoes all the changes to which they are
subject, and disappears with them.
If we examine the interior of the jaws soon after conception,
[six or seven weeks,] we will be convinced of the truth of what
we are about to relate. In fact, the interior of the jaws is, at
this period, filled with a spongy tissue, whose pulps contain the
rudiments of dental follicles. These follicles soon give birth to
[the rudiments of] teeth ; these necessarily expand, and by the
great volume that they acquire, the cellules of spongy tissue, in
the midst of which they are plunged, press on all sides against
the neighborino- cellules, and cause the ridges that separate them
to disappear, transforming them into thin layers of compact sub-
stance, whose reunion constitutes the solid walls of as many cavi-
ties or distinct alveoli as there are crowns of new teeth. And
when these, continuing to increase in height, have pierced the
gums, the roots which follow them, being much smaller, the
remaining space is filled by the closing up of the alveoli.
During the eruption of the milk teeth, the alveolar arch as-
sumes the best arrangement for the accommodation of these
organs, the jaws, as we have already seen, taking the most am-
ple dimensions, sensibly elongate, their angles become more
distinct, the substance of the bones themselves deepen, while
the alveolar borders diminish in thickness after the completion
of dentition.
The temporary teeth having all appeared, is the maxillary
arch always of the same size? Blake and many other anato-
mists, among whom are Scemmering, Sabatier, Boyer, Bichat
and Beclard, his worthy commentator, finally, of a later day,
M. Serres, have thought these arclies elongate during the
whole period between first and second dentition. Hunter con-
tends, on the contrary, that from the age of fifteen or eighteen
12
90 ANATOMY, ORTHOPEDIA,
months, the anterior part of the jaws do not grow, and his
opinion is maintained by Fox* and M. Duval. M. Oudet, hold-
ing this opinion, to the triumph of which M. Mielf has written
a memoir, dedicated to the Medical Society of Emulation, has
taken from twenty children, selected promiscuously, at the
age of three years, plaster models of their teeth ; and after
having repeated upon them, even to the age of six years and a
half, the same experiments, at intervals more or less near to each
other, he pretends to have always found, during this period,
the arch to be uniformly of the same size, and that the relation
between it and the teeth to have undergone no change.
These two extreme and opposite opinions are, according to
our belief, both equally destitute of foundation. In fact, in
admitting the progressive increase and continued growth of
the alveolar arch, Blake has confounded the maxillary bones
with those of their border, in which the teeth are implanted ; for
if the growth of this last was continued uniformly, as those of
other bones, it would exactly follow the laws which govern os-
sification generally, and from whence follows two conclusions :
first, that the temporary teeth, from the moment they appear are
always inclined to separate, and leave a space between them ;
second, that the alveoli, in dilating, abandon, without support,
the teeth they contain. Now, observation proves, although
Beclard and M. Serres assert the contrary, these two facts never
existed. Then the alveolar arch does not sensibly increase be-
tween the two dentitions.
It is this immobility in the alveolar processes, in opposition
to the progressive growth of the jaws, that makes, at six years,
the mental and suborbital foramina still more distant from the
first temporary molar. This immobility, however, applies only
to that portion of the arch which receives the temporary teeth,
for, posteriorly, they are elongated for the reception of the second
adult molars.
But then, if the opinion of Blake is false, is not that of Hunter,
strongly defended by M. Duval, Miel, etc., necessarily conforma-
• Natural History and Diseases of the Teeth, translated by Lamaire.
•f Some Ideas upon the Two Dentitions.
PATHOLOGY AND THERAPEUTICS. • 91
ble to truth? No; for the reason, that if the alveolar arch did
not grow between the two dentitions, it is conclusive, against
the most absolute evidence, that this arch is of the same size in
the infant that it is in the adult. This growth commences at
the moment of the eruption of each tooth of replacement ; it is a
necessary consequence of the intimate dependence in which the
teeth hold the alveoli, which belong to them much more than
to the jaws, and yield to their effort as an elastic barrier, which
permits itself to be extended. Thus it is, that each tooth aug-
ments this arch only in the degree necessary for its own accom-
modation. Nevertheless, let us remark, that this growth is less
than one would naturally suppose ; for observation demonstrates
that if the incisors and canines of replacement are larger than
those of the deciduous set, the temporary molars are larger than
the bicuspides which succeed them, so that what the jaws lose
in space anteriorly, they gain posteriorly. But the same changes
do not take place in the two jaws ; in the superior, the relation
between the gain and loss of space is less as the growth of the
arch which confines this species of fixture, which the superior
maxillary receives with the bones with which it articulates.
And are irregularities of dentition more common in the supe-
rior than inferior jaw?
In order to reduce this question to all possible precision, and
to avoid details that would be more appropriate to a special me-
moir than to an elementary treatise, we may say, the ten teeth
of replacement of the inferior jaw require, in order to arrange
themselves, a space necessary to twenty ; they only find a space
equal to seventeen; of the three-twentieths wanting, they gain
two of them by the increase they themselves occasion in the
alveolar arch, and one by the small space that the two small de-
ciduous molars allow to the two teeth of smaller size which re-
place them. In the superior jaw on the other hand, the three-
twentieths that are wanting after the fall of the first milk teeth,
are obtained, one by the increaseof the alveolar arch, the second
as in the inferior jaw, by the difference in volume between the
two classes of teeth; and finally, the third by the direction of
the incisors, which make room for them by diverging a little.
It is from this slight divergency, so perfect in the adult, that we
\)2 ANATOMY, ORTHOPEDIA,
think the encasing of the two anterior tiers of the inferior jaw
by the superior is occasioned.
We repeat, if the eruption of all the second teeth were to take
place at the same time, their arrangement, doubtless, would be
irregular, since, in the superior jaw particularly, as we have
seen, they would find an insufficient space. But this is not the
case, the fall and replacement of the teeth do not happen at the
same time. These organs have to pass through a series of con-
secutive phenomena, which embraces an interval between the
sixth and seventh years ; thus each, proceeding separately, has
time to advance regularly, and to assume its proper position. If
the anterior arch of the jaws increases gradually, in proportion
to each new tooth, all would place themselve in the semicircular
line that they should occupy ', but if this arch experiences ever
so small a variation, it is generally the canines that cause the
irregularity, because, commonly appearing behind, they are then
obliged to deviate themselves, or cause other teeth to do so, in
order to pass through the gums. This places beyond doubt the
possibility that the teeth possess the ability of causing the alveo-
lar arch to yield ; this happens in cases of supernumerary teeth,
examples of which Camper and Sosmmering have given ; we
have also seen them. This arch in front allows all necessary
space for the accommodation of supernumerary teeth.
Let us examine the intermediate points through which nature
passes to accomplish her desired end, which is to furnish the
jaws of the child with teeth that are most capable of performing
the necessary functions at that period.
The renewing of the teeth according to the progress of their
eruption, commences always with the incisors. The central
inferior incisor appears first ; a short time before the shedding
of the temporary tooth, it gradually elevates itself in the interior
of the alveolus of this latter organ ; it pushes it from below up,
so that the temporary tooth is merely retained at the orifice of
the alveolar cavity. It is at this period that the tooth of replace-
ment effects a slight enlargement of that small portion of the
dental arch to which it corresponds ; the enlargement is visible
a short time before the shedding of the milk tooth, which is
sensibly removed from its neighbors.
PATHOLOGY AND THERAPEUTICS. 93
When, by some cause, the milk tooth is shed at a proper
time, we observe the permanent tooth coming through behind
the dental arch in an oblique position, which causes it to appear
in front of one of its lateral borders ; we at first believe, from its
enormous size, that it is too large to be received into the place
to which it is destined ; it, however, gradually redresses itself
during its progress upwards, assumes a direct position, elongates
and enters into the space that it should occupy ; it then presents
no irregularity of position. What we have just said is applica-
ble to all the incisors, which are subject to like phenomena upon
the dental arch that they occupy.
All the permanent incisors are well arranged during the course
of the ninth year. There the work of replacement stops some
time, and it is only towards the end of the tenth year that we
perceive the first small molar or anterior bicuspid, in whose ar-
rangement we do not perceive the least difficulty, since it has a
volume much less than the molar milk tooth that it ought to
replace. Soon after, the second small molar appears ; then, at
about the eleventh year, the canine, which does not at first oc-
cupy its position upon the line of the arch, but delays to do so
some time.
Very nearly at the same time that the two canines are cut, we
perceive the second large molar ; finally, the last, which is the
wisdom tooth, appears from eighteen to twenty-five years. The
time of the cutting of this last is variable. Hippocrates has fixed
its appearance between the thirteenth and fourteenth septenary.
It is principally among women that this tooth remains sometimes
forever enclosed in the interior of the jaw ; the result of this
generally is a less spacious maxillary bone, without that their
teeth would have less volume. Of all, the wisdom teeth are
most subject to anomalies of form, volume and position. The
following table presents the ordinary phases of second dentition :
From 6 to 7 years, the 4 first large molars ;
" 2 inferior central incisors ;
" 2 superior central incisors;
" 4 lateral incisors ;
" 4 first small molars ;
" 4 canines J
" 7
8
" 7
9
" 8
10
" 9
11
" 10
12
94 ANATOMY, ORTHOPEDIA,
From 11 to 13 years, the 4 last small molars;
" 12 " 14 " " 4 second large molars ;
" 18 "25 " " 4 third large molars, or wisdom teeth.
Total, 32 permanent teeth.
During the replacement of the teeth, some changes that we
should mention are taking place in the jaws. Their bodies
become more extended in height, the suborbitary holes and
mental foramen elongate from the alveolar process and from the
symphysis, and correspond, at about twenty years, to the root
of the second small molar. The crookedness that the base of the
inferior jaw presents, at a young age, disappears gradually, and
becomes angular. The superior alveolar floor contracts trans-
versely at the seventh year, finally enlarges itself very sensibly
in this respect, in proportion as the growth of the horizontal por-
tion of the maxillary bones progresses. The inferior arch does
not dilate sensibly, as we have said, and preserves, crosswise,
nearly the same separation before and after the renewing of the
teeth.
But the most important modifications are those which take place
in that portion of the maxillary bones which corresponds to the
posterior extremity of the arches. That portion of the dental arch
contains, principally, only the first large molars, is considerably
enlarged, in order to receive the wisdom tooth, which ranges
itself behind them ; it is that elongation of the arches posteriorly
which developes the face, and consequently distinguishes the
adult from the infant. In the inferior jaw, it causes the gradual
redressment of its branches, in such a manner as to make them
describe, with the remainder of the bone, an angle less and less
obtuse, whilst to the upper jaw it causes posteriorly pterygoid
apophyses ; that the maxillo-palatine suture, which, in the young
child, was situated opposite the space contained between the
posterior temporary and first permanent molars, corresponds at a
later period to the second, and finally, when the work of den-
tition is completed, it finds itself a little posterior to the wisdom
tooth. The elongation of the posterior part of the superior arch
coincides with the growth of the maxillary sinus, a double effect
which has for its object the development of the large molars, to
II the volume of which it is always proportioned.
PATHOLOGY AND THERAPEUTICS. 96
Phenomena subsequent to the Arrangement of the Teeth.
When the teeth have cut the gams, their crowns have acquired
their full size; but this is not the same case with their roots,
which still continue to increase in bulk and length. As the
roots grow in length, their canals diminish in size, and the cavity
in their crown gradually disappears. The crowns of the teeth,
submitted to the action of foreign agents, become affected by
them; the denticulated edges of the incisors gradually wear
away, the summit of the canines becomes at first smooth, and
then obliterated, and the tubercles of the molars diminish in
size, and finally disappear.
While these changes are going on, the pulp forms new layers
of bone, and the cavity which it occupies gradually diminishes ;
these vascular and nervous communications, and sometimes
even the production of its secretion, becomes altered. When the
teeth arrive at that stage that the blood no longer penetrates their
cavities, and that their nerves no longer communicate their in-
fluence to them, they change in color, become truly foreign
bodies, loosen, and rise from their gums, and finally drop out.
The alveolar processes do not undergo remarkable changes
as long as they are occupied by the teeth ; but so soon as these
organs are lost by disease or accident, the vacuum that their loss
occasions diminishes, fills up, and after a few years disappears.
When once the jaws are deprived of their organs, their bodies
diminish very much in size ; firom this loss of their alveolar
border, they assume the circular form that is had during infancy ;
the suborbital and submental foramina are then near the edge of
the jaws ; the maxillary sinus and tuberosity return upon them-
selves : the branches of the inferior jaw are thrown back, and
assume almost the same direction which they had during child-
hood. Finally, deep wrinkles, prematurely marking the face,
show a loss in the vertical diameter of the face, which consti-
tuted its principal and most handsome feature.
All of this process occurs according to design of nature,
which has caused that the two dentitions, of the divers phases
of which we have spoken, should suffice, in each individual,
through life. There are, however, well authenticated cases of
96 ANATOMY, ORTHOPEDIA,
nature having deviated from her usual course, and that a third,
and even a fourth dentition have occurred.
These new teeth, a freak of nature, as if to show the effort and
resources of the economy, may appear at any period of Ufe after
the time destined for the eruption of the last molar teeth. Their
eruption has been viewed by physiologists and authors who
write upon dentition, only as a curiosity or an unusual occur-
rence; but they merit a more serious recognition, since they
may produce injurious effects to the regular dentition, under
the impression that these new organs have to pass through the
gum nearly of a cartilaginous consistency.
Sennertus* relates a case of a lady who, during her sixty and
some odd years of age, cut twenty new teeth, the eruption of
which occasioned diseases analogous to those which children
experience during first or second dentition Joubert speaks of
of a similar case, of a woman seventy years old ; and a German
author, Ungebauer,t states, that twelve teeth of a child of ten
years of age, were three times shed.
If examples of the almost complete renewing of the teeth pre-
sent themselves so seldom that some authors have thought proper
to deny them, this cannot be urged against the partial renewal
of some. This last phenomenon often occurs, and has been
noticed by men of undoubted veracity, or at such recent periods
that it cannot be doubted. Eustachius, whose anatomiical works
exhibit so much sagacity and precision, has seen the incisors of
a youth, twenty years of age, after having been drawn, to be
replaced by others during the same year. Dufay, physician for
the port of Lorient, has, in that town, seen a man fifty-four
years of age, to whom nature, at that age, had endowed with two
incisors and two canines. Gehler, who has written a work upon
third dentition, relates a case of a canine tooth, which had been
three times extracted, and had been three times replaced by a
similar organ. Haller states that he has seen this phenomenon,
which Cardan and Diemerbroeck had witnessed in themselves,
the former at fifty-three, and the latter at fifty-six years of age.
* Dissertatio de Dentium Dolore.
t De Dentitione Secunda Juniorura.
* PATHOLOGY AND THERAPEUTICS. 97
The most remarkable examples of this nature have been re-
ported by M. Serres, who witnessed them in the charity hospital.
One was a man, aged thirty-five ; his two inferior central inci-
sors dropped out accidentally, and were replaced, within a few
months, by two others. The other case was an individual,
seventy-six years of age, who, when recovering from an attack
of bilious fever, experienced, in the inferior jaw, lancinating pains,
accompanied with tumefaction of the gum and cheek, which
terminated in a multicuspid, situated upon the surface of the
part that the second large molar of the left side had occupied.
The alveolar border of this old man had not been absorbed, the
symphysis of the chin did not project forward, and the angle of
the jaw recede, as it should have done ; hence M. Serres infer-
red that there were other germs of teeth enclosed in the jaws,
and that new teeth would, after a time, show themselves.
The foregoing case of M. Serres may give rise to the following
question : are there in the jaws several germs, or do the germs
contain organs capable of forming and producing new teeth ?
The first of these questions appears to us to be the most plausi-
ble one ; for it is more simple, as the learned author whom we
have just quoted says, to admit that certain individuals may be
born with supernumerary germs of teeth, as we see them come
into the world with supernumerary fingers, kidneys and ovaries,
than to attribute to the teeth the faculty of reproduction. We
have in our possession several pieces of pathological anatomy,
which would lead us to that conclusion, and which the recent
observations of Lemaire and Blandin would confirm. The first
of these gentlemen extracted a canine, from which he readily
detached four distinct teeth ; the second found, in an adult jaw,
a new tooth, the crown of which was partly formed. It is cer-
tainly from such germs that we should attribute the dentition
of old persons.
Functional Importance or Uses of the Dental Apparatus.
The part that the dental apparatus takes in the execution of
the inherent functions of the human organism, is as varied as it
is important ; but of all the attributes which are attributed to it^
13
98 ANATOMY, ORTHOPKDIA,
the most prominent, those to which it is most adapted, from the
nature of its formation, are prehension and mastication. We
will examine these two functions, which, reduced to the physi-
cal properties, according as they are accomplished, resume them
in action : the first, as a pair of pincers to tear and cut ; the
second, as a vice to bruise, and as a mill to grind.
Prehensio7i and JSIastication. — All of the teeth may be em-
ployed, says M. Blandin, in the prehension of solid substances ;
but the incisors are better adapted to this office. Pressing in a
direction opposite to the materials to be divided, they are well
arranged to accomplish this function, for they have cutting
edges, and cross so as to act like the blades of scissors ; but, on
the other hand, placed at the extremities of the jaws, which
there form a lever of the third species, the masseter muscles of
which are the power, the tempero-maxillary articulation, the
point of support, and the body to be divided, the resistance ;
they are so arranged as to exercise great force, especially upon
large bodies, which, requiring the jaws to be opened wide, and
put the elevator muscles of the inferior jaws in the position to act
very obliquely upon the arm of the lever of resistance. Hence,
as all physiologists have remarked, when we wish to break a
hard substance, we instinctively place it far back in the mouth ;
and by shortening the arm of the lever very much, by which the
resistance acts, we correct the lever of the third species, which,
although employed oftener in animal mechanism, is, moreover,
the most useful of all.
The canine teeth, on the other hand, from their pointed shape
and great power, are more adapted to tear than to cut. These
two offices occasion the teeth to be employed both in the pre-
hension of the hand on the one part, and the extensor muscles
of the head on the other. They then act like pincers, with
which we would hold the body that we wish to tear ; the point
of support which they afford in such case is sure, by the length of
their roots, in proportion as they firmly set in the jaws.
As to the molars, their form and position in the posterior part
of the mouth, render them altogether unsuitable for prehension,
except in preliminary circumstances, when the assistance of the
teeth is required for bruising a body, or for holding it, while it
PATHOLOGY AND THERAPEUTICS. 99
is being torn ; ihey afford, in this latter case, much better the
power of retaining objects, as they are placed near the muscles
charged with the office of closing the jaws. But this is not so
in mastication ; they combine the most proper conditions in that
process, which has for its object the faculty of bruising and
reducing food into very fine particles. By the great volume of
the crowns, furnished with asperities, which alternate from one
jaw to the other, they can retain for a long time substances upon
their surface, as if placed between two mills, the office of which
is to triturate them.
We should notice that it is not solely in the arrangement of
the teeth that nature has taken such happy precautions for the
execution of the process which now engrosses our attention ;
she has likewise established the most perfect concord between
the functions exercised by the superior and inferior jaws, and in
such a manner that the former acts like a hammer upon an an-
vil. The superior incisors also, which never have to undergo
forcible offices, are situated below the nasal cavities ; while the
canines find, in the external orbital apophysis of the frontal
bone, a support which enables them to resist the force which is
often required of them, and which, posteriorly, they are com-
pelled to remain strictly tight during mastication, which almost
entirely devolves upon them ; "nature has doubly protected the
superior alveolar border against the base of the cranium, by
placing between them the zygomato-jugale and pterygoiden
columns."
It is not merely the conical form of the roots which concur
mainly to the transmission offerees, by causing the efforts that
they have to sustain to be lost upon the alveolar borders, which
closely embrace them. The number of the roots, are they not
also in proportion to the violence that each class of teeth have
to sustain?
Because each tooth generally has distinct functions, we
should conclude, however, that their action is separate, and that
the labor of some ceases when that of others commences. When
food is once reduced to a proper size, by the teeth, it is succes-
sively carried from one tooth to another, by the combined mo-
tions of the tongue, the hps, and the cheeks, and committed, by
turns, to a vertical pressure and a horizontal grinding.
100 ANATOMY, ORTnOPKDlA,
This process is well performed, when the teeth of both jaAVS
are arranged in the following manner: the superior central inci-
sors close before the inferior central and half of the lateral inci-
sors ; the superior lateral incisors correspond to the remaining
half of the inferior lateral and half of the canine teeth ; the supe-
rior canines pass before the remaining half of the inferiors and half
of the first small molars ; the first small molars of the superior
jaw cover the first and second inferior molars ; the second large
superior molars cover the second and third inferiors ; finally, the
superior dentes sapientise correspond to the inferiors which pass
them, to a greater or less extent.
The great precaution, as can be readily seen, which nature
has taken to render the action of the teeth upon alimentary sub-
stances, are numerous and wonderfully combined, and never-
theless they cannot appear to be exaggerated, except to those
persons who are so blind as to forget the influence of mastication
upon digestion. "When great numbers of the teeth are missing,
so that mastication cannot be continued for a sufiiciently long
time, chymification is with difliculty performed ; the stomach,
irritated by refractory aliment, because it is not sufficiently mas-
ticated, becomes inflamed, and other injurious consequences
arise firom it. Old men, who have lost their teeth, are obliged
to adopt a suitable regimen, under the pain of suffering injurious
consequences ;" if they would not prefer to have recourse to
dental prothesis, which off'ers to them the sure means of pre-
venting these injurious results, as daily experience testifies, and
which we shall very soon attempt to prove.
Articulation of Sounds.
If there is a fact that it sufiices to express, in order that it may
be immediately understood by every one, it is the influence of
the teeth upon the pure and clear articulation of sounds ; for if
the voice is the product of the vibrations that the air exhaling
experiences in crossing the larynx, the word, as Magendie* justly
says, results frem the modification of the voice by means of the
* Elementary Treatise on Physiology.
PATHOLOGY AND THERAPEUTICS. 101
tongue, whose most movable portion strikes at one time the
palate, at another the teeth. But all the teeth are not equally-
important as it regards this : the incisors should be placed first ;
we readily see their want of thickness and, the width of their
faces make them true sonorous bodies, as well as their position
at the confluence of the column of air which escapes from the
mouth ; the canines come next ; then the small molars ; the last
have little or scarcely any influence upon the pronunciation.
The better to appreciate the importance of the teeth in arti-
culating sounds, it is only necessary to observe those who
are deprived of them altogether or in part. Let us notice, in
regard to this, some details, whose recollection will serve at least
in the completion and combination of the different pieces of
dental prothesis.
The loss of teeth is partial or complete, and each of these
circumstances has, in a word, inconveniences which belong to
them, and which vary according as the loss affects the superior
or inferior jaw. For example, persons who have lost the central
superior incisors, cannot pronounce agreeably dental syllables,
which take the labial accent, and their conversation is often but
a continued hissing. If, on the contrary, these same teeth are
wanting in the inferior jaw, the guttural consonants, such as
G, take a sound which is midway between that which belongs
to it and that of Gh and Ch, and which often prevents them
from being understood.
When the inferior jaw has lost all of its teeth, the sound of the
voice is not changed, the pronunciation only is altered ; but it
is not so with the superior; as soon as it is deprived of its teeth,
the alveolar border sinks, and, the palate having lost the con-
cavity that it acquires by the development of the permanent
teeth, the sound of the voice becomes harsh and guttural j for it
is a fact worthy of observation, in every point conforming to
that which establishes theory, that the more the palatine vault
becomes flattened, the less brilliant and forcible the voice, even
among persons furnished with all their teeth ; that which con-
firms this opinion is, that the palate is a vocal pipe like that which
is the parillier to the instrument called horn.
Then, the loss of the teeth has as much more influence upon
102 ANATOMY, ORTIIOPRDIA,
the diminution of volume and force of the voice, as it is more
complete, and as the alveolar border is more depressed. When
they have totally disappeared in both jaws, the voice loses not
only its force, but its harmony ; it becomes, as Delabarre remarks,
sharp and suppressed, the pronunciation can be accomplished
but very imperfectly, and only by a new mechanism, which de-
mands, in every case, a long exercise, often even a painful habit.
Secondary Functional Importance.
The assistance the teeth offer to man is first, in his life, by
nutrition, by the work of preliminary disintegrating that which
is necessary for nourishment ; secondly, in his life by relation,
by the active part that they take in the articulation of the voice,
constituting, as we have said, their principal functions, but
these are not the limits of their physiological acts. Being
placed at the superior extremity of the digestive tube, they assist
in forming a barrier which retains in the interior of the mouth
the saliva destined to facilitate the actions of the different mova-
ble parts of that cavity, and to augment the digestibility of the
alimentary bolus ; approaching the superior members, they are
able to be of assistance to the hands, as a support, to conquer
resistances, and to become even in some cases a means of de-
fence and attack.
Finally, if they exert an action upon the organs, they are also
in their turn influenced by them. Although it seems effectively
paradoxical at first to sustain, by example, that the lips, the
cheeks and the tongue assist, not in giving to the teeth the
proper direction, but in maintaining them in this direction, still
nothing is truer. When the lips are destroyed, the teeth direct
themselves without, whilst they incline inwardly when the
tongue is cut off or diminished in volume. We have had re-
cently occasion of proving this last result, upon a subject who
had long since lost the anterior part of his tongue. We can then
assert certainly, with Blandin, that the teeth are naturally placed
between two forces, which affect them in opposite directions,
the one from without to within, the other fi:om within to without,
and that from this equilibrium results a great part of the sensible
vertical direction that they have amongst us.
PATHOLOGY AND THERAPEUTICS. 103
If, ill order to complete the examination of the Hst that acts
in the economy of organs which we are now treating of, we
wish to study the character that they imprint upon the physiog-
nomy, we should only notice the influence of their loss in this
respect. Now, that influence varies according as the loss is
total or partial, and according as they have a place in the upper
or lower jaw.
For example, the loss of eight or still more of the ten anterior
teeth of the inferior jaw only thickens the lower lip, and renders
the chin pointed, by the retreat upon itself of the alveolar border,
which contains the teeth. If to this loss we add a parallel one
in the superior jaw, the middle part of the face becomes square,
and the physiognomy wears a sad and monotonous aspect. If
it has only a place in the superior jaw, the change is still more
apparent ; for the upper lip, wanting support, sinks in and leaves
the lower one projecting out ; at the same time the nose seems
to be forced in. The molar teeth only, on the contrary, being
wanting, the jaws flatten, become flabby and hanging, and the
form seems elongated. As to the loss of the teeth of both jaws,
the result inevitably is to diminish the vertical diameter of the
head, and consequently to shorten its form.
SUMMARY AND CONSEQUENCES OP THE PRECEDING PHYSIOLO-
GICAL FACTS.
As we have been obliged, in the description of the physiolo-
gical phenomena which belong to the dental apparel, we have
given some discussions and even sometimes made some repeti-
tions, which might be able to cast some uncertainty upon the
mind in regard to the principal points of these phenomena, we
shall briefly recapitulate.
Now, we have seen that all the teeth, as well of the first as of
second dentition, exist in the jaws of the foetus; their develop-
ment takes place in the following order :
1st. After the third month of intra-uterine life, the germs of
the milk teeth are apparent, under the form of a small stony pulp
or papilla, which seems to be but a mixture of vessels and dental
nerves, enclosing, in a sac, a kind of capsule called follicle.
104 ANATOMY, ORTHOPEDIA,
Tiiis folliculous membrane, which we believe to be of a serous
nature, is composed of two leaves, an external one, which is
confounded with the alveolo-dental periosteum, and an internal
one, whose exterior surface is moistened with a sero-mucous
fluid.
These follicles, appended to the gummy membrane, as a fruit
to a horizontal branch, are not developed at the same time, nor
do they offer the same disposition. Towards the middle of the
third month, we distinguish, upon each half of the two jaws,
four sacs, two before, two behind, inclining by pairs, which
leave between them an interval. The first, smaller, belong to
the temporary incisors ; the second to the molars. A fifth sac,
at a later period, fills the interval, for the canine, which forms
the total number of the follicles of the first teeth.
The follicles or germs of the teeth of the second dentition, ac-
cording to Serres, appear after the end of the fourth month ;
those which belong to the two large first molars first, and upon
the same line as the germs of the milk teeth ; afterwards, but
only towards the end of the seventh month, do we see the folli-
cles of the secondary incisors placed precisely behind those of
the primitive teeth to which they correspond.
2d. A little after the appearance of the follicle, the tooth com-
mences to develope itself interiorly ; the top of the crown appears
first. The formation of bone is announced by a reddish circle
around the more prominent parts of the papilla. Afterwards,
the production of the calcareous bony matter, which is effected
by a true secretion, deposited under the form of very fine scales,
encasing the tubercles of the papilla, of which they are equal
in number.
We admit, generally, that of the two substances, the ivory
and enamel, which form the hard portion of the tooth, the ivory
is secreted first. It forms itself upon the surface of the papilla
in circular lines representing horn, which is enclosed from with-
out inwardly, as rolled wafers, and has for the time of its forma-
tion only the development of its roots. The enamel, on the
contrary, is secreted by the external face of the interior leaf of
the membrane of the follicle, and seems to be deposited in crys-
tals upon the crown; but no person, to our knowledge, has
PATHOLOGY AND THERAPEUTICS. 105
explained in an unclouded manner why the crown is the only
part of the tooth which is covered with enamel.
3d. When the first bony cap is formed around the papilla and
envelopes it on all sides, new layers form themselves in the inte-
rior, and are embraced in the last in the whole of its circumfe-
rence, even to its base. Then the crown is formed ; but soon
new layers of ivory envelope inferiorly this papilla, surrounding
its pedicle, descending even to its extremity, and forming the root.
Finally, when the papilla becomes closely covered in all parts,
it cannot extend its functions of secretion, the growth of the tooth
is entirely accomplished, and can never go beyond, as we remark
among rongeurs, who have the central canal of their incisors
extremely extended at its entrance.
It is only towards the end of the last month of gestation that
the solidification of permanent teeth commences, which com-
mences by a speck, which we perceive upon the first large mo-
lar. In the eight first months after birth, the central and lateral
incisors and canines solidify successively. The formation of
small molars rarely takes place before the fourth year; afterwards
the second large molars ; but the wisdom teeth do not ossify
ordinarily until the eighth, ninth and tenth year.
4th. The milk teeth, to the number of twenty, appear ordina-
rily fi^om the sixth to the twenty-eighth month after birth, rarely
sooner, but sometimes later ; their cutting depends upon the time
of their development and solidification ; ordinarily, the inferior
median incisors appear first. All are generally cut at the thir-
tieth month. Their escape from the alveoli, which cannot
contain them, is owing to the progress of their growth, and to
nothing else ; and if they gain their opening sooner than their
base, it is because they are drawn there by the same disposition
of the internal leaf of the capsule, which separates the neck of
the tooth from the gum, to which it strongly adheres.
As to the shedding of the milk teeth, it takes place simulta-
neously with the cutting of the teeth of replacement. This
double phenomena ordinarily commences at the seventh year,
always with the inferior central incisors, and terminates ordina-
rily towards the twelfth year, with the second small molars ;
but it IS preceded for some months only by the first large molars
14
106 ANATOMY, OttTHOPEDIA,
which are permanent, and immediately followed by the second
large molars, which appear five, ten, and sometimes fifteen
years before the wisdom teeth.
As soon as the teeth have come through the gums, they have
acquired the volume they will have during the whole of their
duration. During the interval which separates the cutting from
the shedding of the milk teeth, the bodies of the maxillary bone
increase necessarily, as all the other parts of the skeleton, but
the alveolar arch, properly said, experiences no change in
length ; as the teeth remain always in juxta-position, that which
might not have room in the case or space enlarges itself; they
might leave between them some space. But, at the cutting of
each tooth of replacement, the arch dilates with it, experiences a
growth proportioned to the volume of the new tooth, which it is
ready to receive, and which is undoubtedly larger than those
of the milk teeth.
6th. The duration of the teeth is very variable, and depends
upon the use made of them, the care that they have had, and
the diseases to which they have been subject. In the meantime
we can say that in general they carry, from an early period, the
marks of wearing away, which blunts at first the cutting edges
of the incisors, and at a later period wears oflf the tubercles
which form the summit of the crown of the molars. At their
shedding, the alveoli that were empty diminish, sink down, and
after some years disappear entirely. The jaws once unfurnish-
ed, their bodies diminish in volume, and return again to the
circular form that they had at a young age ; at the same lime
the face loses a part of its vertical diameter.
Such is the summing up of the different phases through
which the teeth pass successively, from the moment of their
formation to their shedding, which happens, unfortunately,
nearly always before their assistance had ceased to be useful to
us ; such are the principal physiological facts which should
serve as a guide in the methodical study of their diseases. But
what consequence shall we deduce in order to establish the
proper degree of vitality which belongs to them ? Is it neces-
sary, in a word, to place them in the range with organic living
tissues, or regulate them in the class of inorganic productions ?
PATIIOLOfiY AND THERAPEUTICS. 107
Let us examine this question without prejudice, and perhaps
we can resolve it simply, in separating from each of the two pre-
vaiUng opinions all that which is exaggerated, and substitute a
less term in the consequences to which each of them has been
conducted, as rules in pathology and therapeutics ; rules which
do not surely accord always with physiological facts which
serve as a basis.
It is natural that the teeth, placed at the entrance of the diges-
tive canal, destined to the laborious functions of crushing the
food, exposed to the attacks of foreign bodies, to the contact of the
air, and to the sometimes rough and violent movements that
the two jaws exercise upon them, should be the most hard and
compact of all bodies that enter into our organization. At no
very distant period, in which they were counted amongst the
pieces of the skeleton, they were considered to possess a vitality
equal to the bones. But from the time that it was discovered
that those of their parts upon which devolved their functions,
their crowns were covered with a calcareous matter of a stony
hardness, which, in its formation, passed through none of the
intermediate points through which the osseous tissue did, and
in which could be discovered neither pores nor cellules, this
opinion was believed to need some modification, and there arose
from it this opinion, that negative characters belong to the tooth
entirely, which belonged only to the superficial envelope of its
crown; that is to say, the teeth were regarded as inorganic
bodies.
It is in vain that the advocates of the doctrine of the vitality
of the teeth, at the head of whom are placed Mascagni, Blake,
Fox, and whose number is augmented by Duval, Delabarre and
Toirec, allege, as a demonstration of the fact, the presence of
vessels and nerves in their bony parts :
1st. That the teeth bleed, that their wounds are painful when
penetrated to a certain depth, and that the acids cause a particu-
lar sensibility in them, as also certain caries and some superficial
wounds.
2d. That they become discolored when an animal is nourish-
ed upon madder, and that in certain diseases they take a tint, red
in the cholera and some cases of asphyxia, yellow in the jaun-
108 ANATOMY, ORTHOPEDIA.
dice, blackish in adynamic fevers, whitish in diseases attributed
to lymph.
3d. That their fractures or solutions of continuity perfectly
cicatrise, and that they will become impaired as promptly as
artificial teeth, if they contain not the elements of organization.
The advocates of the contrary opinion, supported in their
researches by Eustachius, Duveney and Hunter, to whom the
illustrious Cuvier has lent the aid of his name, have replied :
1st. That if deep wounds furnish blood and cause sharp pain,
these result from the papilla being affected ; that the phenome-
non of teeth set on edge can be explained by the imbibation of
the ossiform part or of the calcareous layers, and by the direct
action of an acid upon the papilla, and that the wounds and
superficial caries develope only the pain, by producing the de-
struction of the tooth, and by rendering their external envelope
less fitted to preserve the papilla against exterior agents.
2d. That the coloring of the teeth by madder deposes much
more against than for the vascularity of the teeth ; for if the ex-
perience of Hunter establishes that, in these cases, the coloring
matter is deposited in the parts of the teeth which form during
the time that experience contends, they have proved, also, that
the parts first developed preserve their primitive color; that
which happens to the true bone, which, under the influence of
madder, colors it in every instance red ; as to the color that they
take in certain diseases, they owe it to a simple imbibation,
whose materials are conveyed into the dental cavity by the
nourishing vessels of the papilla.
3d. "That if fractures cicatrise, it is always the result of a
new ossiform production, secreted within by the papilla ; and if
the natural tissue of the teeth is not impaired as artificial animal
teeth, it is by an analogous reason to that which causes the
nails not to dry so much as to remain adherent to their matrix,
because they are surrounded by parts which keep them mois-
tened with a substance which they imbibe, and which maintains
them in their normal state."
As we see, if some of the objections made to the vitality of
the teeth seem established, others also seem more specious than
solid ; for example, in taking in the following order, in which
PATHOLOGY AND THERAPEUTICS. 109
they were stated, we are forced to avow that the phenomena of
teeth set on edge is sometimes too quick, and depends in some
instances upon causes too light to be explained by the imbi-
bation of the ossiform part or of the two calcareous layers of
the teeth, which, at an advanced time of life, form nearly all
the thickness of the crown.
To maintain, in the second place, that the coloring of teeth in
certain diseases, is owing to imbibation, is to avow that their
ossiform tissue is so permeable that it permits itself to be pene-
trated by every colored liquid with which they come in contact,
that which is not positively certain, and which does not explain
how they take their normal color at the recovery from the dis-
ease ; or it is to admit that the vessels of the papilla continue in
the ossiform part. As to the inductions which are believed to
be drawn from the manner in which, according to Hunter, the
teeth are colored under the influence of madder taken as nour-
ishment, we have already said that Flourens has proven that
they rest upon facts badly observed.
Finally, to explain the cicatrization of fractures of teeth
by the secretion of a new ossiform substance, is, on the one
hand, to forget that we have recognised in principle that the
secretory functions of the papilla cease entirely when, by
the complete formation of ivory, it is reduced to a nervo-
vascular cord which forms its centre ; and it is, on the other
hand, to assimilate the teeth to bones, whose fractures con-
solidate as by a new calcareous cellular production. As to
the insensibility of the teeth in their healthy state, we know
nothing to allege against their vitality, for we acknowledge in
man diverse white tissues, which only have the property of feel-
ing when in a pathological state.
Besides, this insensibility of the teeth is not as absolute as
one generally believes ; for all, in recognising that the very dis-
tinct perception of the sound of a watch placed between the
teeth is the result only of the sonorous vibrations communicated
by the teeth to the jaws, by these to the skull, to the labyrinth,
and from thence to the brain ; one cannot deny, however that
they are susceptible of receiving certain impressions, and of
transmitting them to the common sensorium ; cold and heat,
110 ANATOftlY^ OT1TII0PEDIA,
carried to a certain degree, affect them disagreeably ; finally, we
are able, by them, to know the qualities of certain bodies,
which are accidentally placed in contact with them, that which
we would be unable to do by artificial teeth, of whatever nature
they might be.
We well know, although, to explain the impressions of heat
and cold, and the sensations resulting from mechanical action
received by means of the teeth, it is said that they first act upon
the nerves and vessels of the dental pulp, to which they are
transmitted across the thickness of the crown, and that the
second are communicated by the membrane which envelopes
all the length and each division of the root. But this explana-
tion, satisfactory at first, ceases to be valuable when we reflect
upon the tenuity of the dental pulp, especially at an advanced
age, and upon the thickness of the two calcareous layers of the
crown. Thus Beclard,* in these days, seeing the insufficiency
of this explanation, said that, '■Hhe crown of the tooth is formed
of an organic animal matter, which one could not believe vascu-
lar." It were nearly as well, as every one perceives, to admit
that it is sensible.
Still later, Blandin, acknowledging that the dental osteoide
possesses, in its superficial layers, a peculiar sensibility, accom-
panying certain caries,t commencing between the enamel and
ivory, &c. <fcc., has thought that it might be possible that this
sensibility was inherent in the ^greyish line, intermediate be-
tween the ivory and enamel, that Cuvier believes it formed by a
prolongation of the internal lining of the follicle, and in which
some one of the nerves remains, that this lining possessed before
having been taken between the two substances of the tooth,
even at the moment of their formation.
Certainly, if it was thus through it, the instantaneousness of
the phenomena of teeth set on edge would be understood more
*Dictimary of Medicine, vol 6, article Teeth.
t This feet presents itself so often to the observation, that we cannot con-
ceive how Leraaire could have declared that, in diseases of the teeth, the
pain manifests itself with violence, when a part of the substance of the
crown being destroyed, as far as the cavity, the pulp was discovered.
PATHOLOGY AND THERAPEUTICS. Ill
easily, since, in this manner of viewing it, the acid which pro-
duces it would have need only of imbibing the enamel, a sub-
stance little thicker, and thus it might act nearly at the point of
contact. But this explanation is a pure hypothesis, for there is
litfle logic in inferring from the sensibility the existence of a
membrane which has long since ceased to be, and whose former
existence is affirmed only from a linear mark ; this might cast
in the shade the inherent properties of the body which produced
it ; in a word, realise a pure chimera.
Is it not, then, more reasonable, and more conformable to that
which daily observation demonstrates, to admit, that of all parts
of the teeth, the enamel alone is deprived of life, and conse-
quently insensible ; that the ivory, essential production of the
papilla, is united to it by relations foreign, and contact too
intimate not to receive, under some form, even inaccessible to
our senses, a part of the agents of its excessive vitality ? All
the question relative to the presence or to the absence of vessels
and nerves of the ossiform part of the teeth are summed up in
these : the teeth have three distinct parts in them ; the central
organ or the pulp, which is essentially the nervo- vascular part,
and consequently the most vital ; the ivory, which protects this
pulp, and which, although less sensible, is sufficiently so to
avert the presence of hurtful agents; finally, the enamel, abso-
lutely inert, which is there only to protect the other two sub-
stances from all attacks of strange bodies.
There are, as for the rest, from our own experience, numerous
facts, which appear to us most conclusive in demonstrating not
only that the ivory is not insensible, but that it possesses a sen-
sibility sufficiently marked, and which it exerts even promptly.
Let any one introduce into the cavity of a tooth, newly extract-
ed, entire and provided with a central canal still very marked, a
little stem of wood or of iron, colored with blue turnsole, and
let the crown of that tooth be touched with a pencil impregnated
with some acid ; if the instantaneous setting on edge which
follows the application depends, as it is commonly said, and as all
the world has formerly believed, upon the action upon the dental
pulp by that acid, which suddenly imbibes all the ossiform part,
that action will be perceived by the blue color which has filled
112 ANATOMY, ORTHOPEDIA,
the canal and turned it red. Well, this does not suffice, for it is a
long time before this color is affected by the acid. We have
even held the crowns of teeth, whose canal we had filled with a
purple fluid, plunged in vinegar, (acetic acid weakened with
water,) many minutes, with this liquid becoming reddened.
Then the setting on edge has its seat primitively in a part situ-
ated less deep than the pulp, and which could only be the ivory.
Our opinion, as is perceived, has the double advantage of
rendering as satisfactory account of the physiological phenome-
na of which the teeth are the seat, and of avoiding the whimsi-
cal contradiction into which the most of authors have fallen,
which, after having strenuously denied all traces of the organi-
zation of the dental osteoide, they please, nevertheless, to de-
scribe the diseases by which it is so frequently affected, and of
which development no one could logically explain, except by
the laws of general vitality.
CHAPTER III.
DENTAL HYGIENE AND ORTHOPEDIA.
We have hitherto been occupied with the anatomical and
physiological facts which constitute the science of the surgeon
dentist. But here commences his real art ; for we are about to
describe, under the name of dental hygiene, a methodical expo-
sition of all the cares and precautions which are intended to
facilitate the development of either dentition, or to preserve the
teeth in a constant state of health and cleanliness. We will
append to this chapter, under the name of orthopedia, and in
accordance with the true acceptation of the word, now much
used and well understood, a series of means which, although
requiring the application of the hand, cannot, nevertheless, be
properly considered as operative surgery, inasmuch as they ad-
dress themselves to conditions which, properly speaking, are not
diseases. Such are the straightening, shortening and separating
of the teeth : matters with regard to all of which we arc about
to announce precepts which are rational and of easy application.
PATHOLOGY AND THERAPEUTICS. 113
Sec. 1. — Of the Means of Directing the Eruption of the Teeth^
and Facilitating their Arrangement
First Dentition. — If we must believe the most of the authors
who have written upon the diseases of children, during the las
century or early part of this, or even of the dentists who, in our
day, have published special treatises under the influence of the
opinions of these authors, the eruption of the teeth, (particularly
of the first dentition,) although performed in the order we have
described in the preceding chapter, is an epoch so fearful that
few children can pass through it without being assailed by
dangers, capable at any moment of destroying their life.
But when we take the trouble to study nature without preju-
dice, and, above all, to judge by the facts, we easily escape from
the exaggerated opinion which makes us see a continual cause
of death in the execution of a natural function; and, in a great
number of cases, we find one of two things: either that the
eruption is entirely unconnected with the diseases which attack
children at this period, or that it often is but a secondary cause
of their existence, by putting in action morbific causes, to which
the organs, the seat of these diseases, are predisposed; which
would equally have been eff'ected by any other stimulant.
This exaggeration once perceived, we must not fall into the
contrary extreme, by refusing to admit that the escape of the
teeth from the alveoli is one of those processes which nature
rarely undertakes without effort; an effort accompanied, almost
always, by pain, and which may also, under some circumstances,
be the direct cause or simply the index of accidents sufficiently
serious to claim serious attention. The trouble resulting from
it may even cause itself to be felt in every part of the economy,
or at least throughout the whole extent of the two organic sys-
tems which predominate in infancy, those which preside over
nutrition and sensibility.
But why is the cutting of the first teeth often a laborious
function ? Is it due to the piercing the gum, or the dilatation
of the gubernaculum dentis, as we adopt the old or new theory
of the mechanism of the eruption 9 Though, while replying to
this question in the affirmative, we cannot render an exact ac-
15
114 ANATOMY, ORTHOPEDIA,
count of all the morbid phenomena which may happen at this
time, we are, nevertheless, compelled to adhere to the opinion,
for it promises to explain, to a certain extent, the most prominent
of these phenomena. We know, indeed, that the local inflam-
mation arising from a laceration or a simple dilatation, might be
sufficiently great to irradiate itself upon the mucous membrane
of the digestive and respiratory passages, and their appendages,
and give rise to discharges aphthae, ophthalmia, and even
otitis, which often appear, and it will suffice to bring to mind the
nervous disorders which laceration of tissues excites, to explain
the convulsive movements which may accompany laborious den-
tition. As the description of these different accidents, and the
treatment appropriate to them, belongs necessarily to the province
of general pathology, we will not consider them here : the dental
surgeon is rarely called upon on such occasions, or if he is, it is
only required of him to attend to the local conditions of the ap-
pearing tooth. Instead of uselessly swelling this work, by copy-
ing what belongs to treatises on general pathology, it will suffice
us to remark that the particular constitution of each child has
much to do with the occurrence of these accidents ; that they oc-
cur most commonly during the eruption of the eight small molar
teeth, that is to say from the second to the third year ; that they
are more common to feeble, delicate, badly nourished children,
or those born of nervous parents, than to others ; finally, that the
most efficacious means of prevention are to accustom them from
birth to the changes of atmosphere, to subject them to insolation,
frictions, and all other means likely to counteract the nervous
constitution so common to children born in large cities.
From the fact that the morbid phenomena just described cease,
often instantaneously, in the midst of the greatest intensity,
fi'om the moment that the teeth penetrate the gums, which re-
tained them, and compressed their pulp at the bottom of the alveo-
lus, has arisen the precept to divide that barrier when it opposes
too much resistance. This little operation, which is effected
with the point of a thin bistoury, the blade of which is guarded
with linen for the space of four millimetres from its extremity,
will often succeed so immediately as to cause regret that it had
been so long postponed. In some cases, unhappily, premature
PATHOLOGY AND THERAPEUTICS. 115
and ill timed incisions close again without any advantage to the
child, as M. Guersant,a physician who has, in our time, devoted
himself very successfully to the diseases of children, has fre-
quently observed; a fact which seems to justify the supposition
that the tooth thus denuded is propelled less rapidly than others.
It has also been remarked, that the incision of the gum has
favored caries, either because the teeth had been scratched by
the point of the instrument guided by an inexperienced hand,
or because they had been exposed before the enamel had be-
come perfectly matured, if we may be allowed the expression.
We must conclude, then, from all we have said, that while the
incision may be a means approved by reason, and, in many
cases, sanctioned by experience, we must not have recourse
inconsiderately to a practice which the children always resist,
and which frightens the parents. Before proceeding to it, we
must be very sure of the imminence of the eruption, and the
necessity of accelerating it ; which may be ascertained when
the tooth projects under the gum, and seems ready to break
through it. In other cases, we may content ourselves with
making the child chew some body of moderate resistance, or a
hard body so polished as to lessen the danger of violent pressure.
A crumb of bread, a piece of liquorice root, or of mallow, an-
swer, if there be tumefaction of the gums : corals, or pieces of
ivory or crystal may be better, if the eruption be yet distant and
the gum not swollen. Finally, general means should not be
neglected, especially such as tend to lessen the excitability of
the sanguineous and nervous systems.
But, we repeat it, it is especially in the wise application of
hygienic principles that we must seek the means to prevent the
storms which threaten first dentition, and reduce that function
to that state of harmlessness which it ought naturally to present.
Certainly, as a modern author rationally remarks, by the aid of
these precepts, we will be more likely to reach the desired end,
than by amber necklaces, serpents' teeth, and the crowd of
amulets which ignorance and creduhty confide in, and which
some dentists, careless of the dignity of their art, have yet the
wickedness to advise, or the weakness to authorize.
116 ANATOMY, ORTHOPEDIA,
Second Dentition— Indirect Means to Prevent Errors.
The cutting of the second teeth, called teeth of replacement,
permanent, or secondary, is surely always less painful than that
of the primitive or temporary ones. But, although the remarks
we have made with regard to the exaggeration of the dangers of
the first dentition apply still more forcibly to the case of the
second, it is not the less true, whatever may otherwise be the
constitution of the child, that the part of the gum surrounding
the tooth to be replaced is almost always slightly inflamed.
This inflammation, which rarely proceeds without pain, and
sometimes terminates by little local abscesses, does not confine
itself to the mouth, for it sometimes, upon slight provocation,
extends to the surrounding parts. We even encounter, at this
time, inflammatory and nervous accidents which attest a shock
communicated to the whole economy, and accompanied always
by indigestion, to which, moreover, the obstacle which the
loosening of the milk teeth presents to regular mastication, is a
further inducement.
It is principally when the small molars, or molars of replace-
ment appear, which happens at the tenth or twelfth year, that
children experience a feeling of malaise^ and general indisposi-
tion, which can only be properly attributed to the efforts of nature,
occupied with the replacement of the temporary teeth. In the
second period, or what may be called the third dentition, that is
to say, at the appearance of the second and third great molars,
though eflfected at an age when the system is in a better state to
resist, we sometimes encounter very serious morbid conditions,
as we ourselves have frequently observed.
As in these last cases, there is more reason to attribute the
accidents to the resistance of the gums, than those which occur
during first dentition ; it is prudent to proceed, as promptly as
possible, to incise the tumefied gums, and even useful to scarify
the surrounding parts with the point of a lancet. But we must
not forget that these means will prove altogether inefficient, if
the accidents which accompany the eruption of the teeth depend
either upon the too close pressure of the teeth upon one another,
or upon the want of space between the coronoid apophysis and
PATHOLOGY AND THERAPEUTICS. 117
the second large molar, impeding the wisdom tooth. Their ex-
traction is then indispensable, unless the difficulty of getting
hold of them shall determine the operator rather to remove one
anterior to them, so that they may occupy its place. This
is generally the plan adopted, as the following case, given in
the clinique of Prof. Velpeau, and belonging to the particular
practice of M. Toirec, will show.
Mad. R. experienced, two or three months after her marriage,
a dull pain at the angle of the lower jaw of the left side ; the
pain soon extended to the median line. Some months having
passed in this condition, and the pains becoming daily more
acute, a rheumatism was suspected, and different curative mea-
sures were employed. After a consultation of physicians. Mad.
R. was sent to the springs. After her return, still suffering
great anguish, she came to consult me. The face was pale and
contracted, the emaciation of the body extreme, the appetite
gone. The calm of the night seemed to augment her despair.
The teeth, examined with care, were sound, white and well
arranged ; the gums in their whole extent were of a pale rose
hue; nothing gave evidence of the cutting of a wisdom tooth.
Nevertheless, I directed my researches to that point. I made a
deep incision upon the gum, behind the second great molar. A
small sound introduced, discovered a hard, shining body, around
which I could pass the instrument, except in front, where it was
arrested. 1 did not hesitate to believe that there was a tooth,
directed obliquely from behind forward, the crown of which,
resting upon the neighboring molar, was arrested by the latter;
nor did I delay to extract the second large molar,' to favor the
escape of the wisdom tooth. Gradually the suffering disappear-
ed, and five or six days after the operation, she ceased to feel
the slightest pain."
M. Blandin also has been called to remove one of these teeth,
which, locked up in its alveolus, as it were rivetted by bone,
had occasioned fistulous openings, against which all the re-
sources of art had been exhausted.
Finally, one of the most striking examples of the tardy, slow
and difficult escape of a wisdom tooth happened to one of us,
who, being at Moscow in 1804, extracted from Dr. Saint-Marie,
113 ANATOMY, ORTHOPEDIA,
then sixty-four years old, one of this kind of teeth, which he
had but lately cut, and by which he had been incommoded, at
different times, for more than thirty-five years.
Direct Means to Prevent Errors of Second Detitition.
We again see that there are pathological phenomena which
signalize the replacement of the teeth, as well as those which
appear at the epoch of their first eruption ; to prevent these acci-
dents, and apply to them suitable treatment under all circum-
stances, belong properly to general medicine. But the sym-
metrical arrangement of the teeth is especially the work of the
dentist. What, then, are the means proper to favor this ar-
rangement? Is it necessary, as some ancient authors, and
many modern ones, have pretended, to take out early the primi-
tive teeth, or rather to seek to preserve them until they naturally
fallout?
It is difficult to establish, in this respect, a precept rigorously
applicable to all cases. We may, nevertheless, say, in general
terms, that unless it is evident that the primitive tooth is an
obstacle to the appearance of that which should replace it, the
extraction is, to say the least, useless. It is to extend the sphere
of our operations, but not to respect physiological function. But
in the case, on the contrary, where the tooth is a mechanical
cause, hindering the permanent one from developing itself
properly, or to place itself in its proper position, there is a further
indication, an absolute necessity, to remove it ; for by delay we
expose the child to irregularity of denture, a deformity easier
prevented than cured.
This operation has for a long time been opposed by the fear
of removing, with the milk tooth, the germ of that of replace-
ment ; but this fear can now have no influence, except for
practitioners who do not know that fi:om the age of four and a
half or five years, this germ is entirely ossified, and no longer
touches the primitive tooth, whose root begins to disappear.
This disposition, however, is subject to variation : hence we
often see the crowns of permanent teeth push so exactly from
below those to be replaced, that they are, so to speak, dove-
PATHOLOGY AND THERAPEUTICS. Il9
tailed into each other. We perceive how, in such a case, the
evulsion of the milk tooth might be prejudicial, for it would
almost infallibly cause the loss of the secondary one.
But, we repeat it, as much as it will be improper to temporize
when there is indication, there will be equal impropriety in too
much haste ; for when many teeth are extracted before they are
loosened, the temporary ones do not arrange themselves so pro-
perly, or level themselves so equally as they ought. Take away
the four incisors ; they are replaced ; but those that appear, be-
ing larger than those which are lost, necessarily force the canines
out of place, and dispose them to loosen too quickly. The small
molars are taken away; those which should replace them, no
longer finding the lateral resistance which the canine, as a
guide, should offer, advance freely forward, and occupy its
place; in such a way, that when the canine of the secondary
set appears, finding no place for itself, it falls within, or more
commonly without, the dental circle.
Another reason for objecting to the premature evulsion of the
milk teeth, is that their presence may aid the enlargement
of the alveolar circle, which, at that age, is yet much under its
complete development. We nevertheless frankly confess, that
in sound physiology we cannot attach to the presence of these
teeth as much importance as has commonly been attributed
to them, and for two reasons : first, because the milk tooth
arrived at the natural term of its fall, has no or almost no root
implanted in the alveolar border, and is not firmly enough fixed
to furnish the slightest point of support : the second, that already,
as we have said, the germ of the secondary tooth is completely
ossified, and occupies, in the thickness of the alveolar ridge,
a space which the fall of the primitive tooth cannot diminish!
Hence, Fox properly observed, "The advantage of extracting
these teeth will depend entirely upon whether it is done at the
precise moment when nature proves backward in effecting the
absorption of the roots of the temporary teeth. To avoid
operating unadvisedly, we must thoroughly understand the
progress of second dentition, and observe exactly the appearance
ofthe gums, which swell when a tooth is upon the point of
piercing them.
120 ANATOMY, ORTHOPEDIA,
We further quote from this skilful practitioner, who, without
doubt, has discussed this question most ably :
"To aid the permanent teeth in ranging themselves in suita-
ble order, it does not suffice to extract those which obstruct, for
considerable time will always be required to enable the irregular
tooth to resume its natural position; often, indeed, it fails to
abate its irregularity altogether. We ought, therefore, to ex-
amine the mouth of a child frequently, so as to be able to make
the extraction opportunely. The absorption of the roots of the
temporary teeth is sometimes performed so slowly that they do
not loosen until the permanent ones have pierced the gum be-
hind them ; in such a case, if the permanent molars have ap-
peared some time before, and if there be engorgement of the
gums behind the two permanent central incisors, we ought to
extract the two temporary central incisors, which correspond .to
them, even though they be not loose. When the absorption of
the roots of these incisors has been prompt, which often occurs,
these teeth shake, and the child can easily remove them himself,
a little before the appearance of the new ones. But often, though
they be loose, they do not fall of themselves before the perma-
nent ones appear ; in such cases it is useful to extract them, in
order to give to those which ought to succeed them, the facility,
of taking their proper place. If, as we might soon detect, the new
teeth have not sufficient room to develope themselves, it will be
necessary to extract the two temporary lateral incisors.
"Two or three months afterwards, or even later, it will be
time to give attention to the central incisors of the upper jaw.
If we find them loosened, it will be proper to extract them ; if
they are yet firm, and the gums be engorged, they should also
be extracted ; for if they be left in place, the permanent ones,
which are ready to appear, will take an irregular direction, ugly
and hard to correct. It will also be proper to extract the lateral
incisors, to procure to the permanent central ones the space
needed for their development, but this should not be done until
it is time for the latter to pierce the gums. Afterwards, tfee
lower jaw should be attended to, when the incisors should ap-
pear at the end of three or four months. If we perceive any
sweUing of the gums through which they must pass, we should
patholo(;y axd ther afkutics. 121
extract the temporary cuspidati ; three months afterwards, at the
furthest, we must examine the upper jaw, and if we perceive
that the permanent lateral incisors give signs of near appearance,
we should also extract the temporary cuspid ati.
"After this, the jaws will often require no further attention
until the end of a year, when the incisors are entirely developed.
After this, the cuspidati and bicuspides are ready to appear; then
we must be on our guard, to prevent the first taking an irregular
position. We must examine the gums, and if they are promi-
nent, we should extract the first temporary molars ; these often
are loosened, (Fox might have said most generally,) before the
appearance of the cuspidati, which follows hard upon their ex-
traction. Some circumstances should exercise much influence
over the manner of treating these latter teeth. If, when one or
the other of the cuspidati is ready to appear, we perceive that
there is only a small space between the lateral incisor and the
first bicuspid, already in its place, we must be careful to extract
the second temporary molar. The bicuspid will then fall back,
and give the cuspidatus a sufficient space.
"After this last operation, there remains no furtlier obstacle to
second dentition. The second bicuspides come naturally into
their proper place, and the molais, encountering no opposition,
successively occupy their proper position."
Sec. 2. — Of the Different Means of Preserving the Teeth.
When the teeth naturally occupy their assigned places, or
have been artfiiUy conducted to them in the mode which we
shall soon describe, it is necessary to watch their condition and
preserve their health. So many causes are continually acting
to alter them, that it is not surprising that it has always been
felt necessary to preserve their health by care. Hence we find
in all the works on medicine, ancient or modern, judicious advice
for their preservation, and if we consult general history, we will
find that many people have attached so much importance to
their preservation, that they have made it a part of legal require-
ment, a religious lu-ecept. Some savage tribes, in that depravity
of taste which accompanies ignorance and barbarism, have sub-
16
122 ANATOMY, ORTIIOPEDIA,
jected their teeth to horrible mutilations, outraging nature in
their efforts to adorn it ; but all civilized people, with whom the
cultivation of the arts has proven that the beautiful is allied to
the good, have all agreed as to the importance of a healthy and
regular mouth to an agreeable appearance ; and the kind of care
necessary to the different organs it contains.
The preservation of the teeth, as of all parts which compose
the body, depends evidently upon two kinds of care. The first
is general, that is, does not regard the teeth except as they are
affected by laws regulating the entire economy ; the others are
special and particular, that is to say, exclusively applicable to
them. Let us first examine the former, confining ourselves to
what is particularly connected with our subject.
General Cares.
The choice of food is certainly the first of the precautions
which any person who values his health, and consequently his
teeth, should observe. But it is impossible, in a work such as
this, to trace precise rules for this selection. For the constitu-
tion of each individual being the first thing which he should
consult, it is evident that the best aliments for him will be such
as tend to moderate the tendencies of his temperament to disease.
We may, nevertheless, say, in general terms, that animal
food is less favorable to the preservation of teeth than vege-
table diet; and this for two reasons, first because animal
food conveys to every part of the system exciting principles
which no organ, the teeth no more than others, can well
sustain in excess ; secondly, because it is difficult to remove
from between the teeth the residue of meats, the presence and
decomposition of which is a cause of local alteration.
The abuse of green fruits and other acid substances is hurtful
to the teeth ; alcoholic liquors also do harm, if not through their
chemical action, yet because they inevitably keep the gums and
mucous lining of the digestive organs in a state of excitement,
which the teeth will assuredly suffer from.
It is a matter of observation, that all food which contains
sugar is injurious to the teeth. To explain this, we may observe.
PATHOLOGY AND THERAPEUTICS. 123
that when alone and under a solid form it acts as all powders of
a gritty kind ; and when in syrup or otherwise dissolved, it runs
under the teeth, subjects them continually to the action of air,
and makes them the seat of a morbid susceptibility, which may
be the prelude to caries. The sensation (setting on edge) which
it produces with many, seems to be explained upon this hy-
pothesis, and indicate the necessity of moderation in the use of
this article.
Every body knows that the use of well-water rapidly injures
the teeth, and what the chemical analysis of these waters would
lead us to suspect, experience demonstrates. Indeed there are
few persons, who reside in places where river water is inacces-
sible, who have not lost the greater part of their teeth before they
were forty ; this is especially the case with women. For the
same reason, persons resorting to mineral springs usually return
with their teeth in bad condition. Waters containing carbonic
acids, free or combined, are those which produce the most
remarkable effects.
The composition of aliments is not the only thing to be re-
garded as influencing the teeth ; we must also attend to their
temperature. Pains should also be taken to avoid the habit of
cracking nuts, bones, etc., with the teeth, or of drawing corks
with them, especially if they be badly planted and have long
crowns, this longitude being in inverse proportion to that of the
roots. As to the precaution relative to the temperature of ali-
ments, it consists in not only shunning the two extremes, but
passing rapidly from one to the other. Hence it is a bad habit
to drink cold drink directly after soup. We may readily sup-
pose that the rapid transition from a state of high excitation to
the contrary, may dispose the pulp to inflammation.
"Next to aliment and air, clothing should most claim the
attention of persons anxious to preserve their teeth. The most
important precaution, so far as the air is concerned, is to avoid
extremes of heat or cold, and especially the rapid transition
from one to the other. Under the influence of the latter cause
the teeth may be altered in two diflferent ways, directly or secon-
darily: directly, by the lively stimulation that the cold imparts
to the vessels and nerves shut up in the dental canal ; seconda-
124 ANATOMY, ORTHOPKDIA,
rily, by the rapid suppression of the transpiration, which is
thrown back upon the mucous membrane of the mouth, and
from it upon the teeth, causing those inflammatory swellings of
all the walls of the mouth, generally called "■Jiuxions.^'' It is prin-
cipally in this way that we may explain the destruction of the
teeth of smokers; for, as we have long remarked, it is not the
pipe which hurts the teeth, as is generally supposed, for it only
acts mechanically, but rather the cold air, which, penetrating
the mouth, whose walls are moist, sometimes creates an inflam-
mation of the dental pulp, whence may arise a caries, which
commonly developes itself upon those which, from structure
and position, are already inclined to that disease. The expe-
rience of M. Donni confirms our own observation as to the
harmlessness of the fumes of tobacco as a chemical agent. In
his excellent treatise upon the properties of saliva, he says, "It
is true that tobacco conmiunicates to the saliva a certain very
sharp acridity, very unpleasant to those unaccustamed to it, but
it does not render it at all acid, as I have fully convinced my-
self; hence we cannot say that smoking alters the saliva, since
it still preserves its alkaline quality, and may still neutralize
gastric acids," (fcc.
Women are indebted to their extreme impressibility, and to
the fatally imperious yoke which our habits and prejudices im-
pose upon them, for the sorrowful lot to be more exposed than
we are to the sad action which the causes under consideration
effect. They should never, if they would preserve their teeth,
quit suddenly warm clothing for that which is thinner ; never
wash the head with cold lotions ; never walk on cold ground
with thin shoes, &c.
Among the toilet articles which may hurt the teeth, we may
mention the several kinds of paints, waters and pomades intend-
ed to remove freckles, &.c., from the face, or to color the hair.
These cosmetics, almost all of them, contain astringent and
even caustic substances, as antimony, bismuth, the hydro-
chlorates of mercury and lead ; substances which act directly
upon the teeth, to which they are carried by the lymphatic
vessels, which, proceeding from the skin, ramify upon the buc-
cal mucous membrane, enveloping the neck of the teeth, and
PATHOLOGY AND THRRAPKUTICS. 125
entering the alveolar cavity. Those who, from their position,
are compelled to use these substance, ought, as far as possible,
to confine themselves to such as are purely vegetable ; if these
are not harmless, they are at least less injurious to the teeth.
It has always been remarked, that persons living in low, wet
places, near to lakes or marshes, as inhabitants of valleys, and
those who reside in ports where the temperature changes fre-
quently during the day, generally have bad teeth. As to work-
men, constantly employed in factories where the air is continu-
ally charged with metallic particles or acid vapors, capable of
combining with the constituent parts of the teeth, it is possible,
if not to protect them completely against these pernicious ema-
nations, at least to lessen the danger of them, by properly ven-
tilating the rooms, and by inducing the workmen to wear masks,
as Dr. Loude advises, furnished at the part corresponding to
the mouth, with a number of httle pieces of sponge, upon
which the mineral or acid emanations may condense without
entering the mouth.
Special Cares.
By pursuing the general precepts which we have just laid
down, undoubtedly a great number of the diseases of the teeth
may be prevented. But these will hardly avail, if we neglect
the particular precautions, which are none other than the cares
of neatness, which form the daily "toilette" of the mouth. These
are simple, and hardly require to be named. But as people
sometimes with the best intention suffer themselves to be led
by a blind routine, we ought to omit no details which may lead
to a proper appreciation of these daily cares.
As the milk teeth, for the most part, require no care, we may
say that we need not accustom children to the toilet of the
mouth until the eighth or tenth year ; but after that time they
should be taught to regard this as an imperative necessity, caus-
ing them to use, every morning, water, moderately warm in
winter, and of natural temperature in summer. The use of the
brush is, to say the least, useless at first, for it would only dif-
fuse over the gums and teeth the mucosities collected during
the night.
126 ANATOMY, ORTHOPEDIA,
Pure water will suffice, ordinarily, until the fifteenth or eigh-
teenth year; but after that, (and sooner, if any local affection
or derangement of digestive or respiratory organs should taint
the breath,) the water should be qualified with a few drops of
some aromatic spirituous liquor, such as Cologne water. After-
wards, we should use some kind of dentifrice, with which we
should rub, in every direction, not only the teeth but the gums.
Should this dentifrice be applied, simply by using a piece of
cloth or a corner of a towel rolled round the finger, as is the
habit of some who wish to simplify their wants ? Certainly not;
for the pressure of the linen must certainly amass and harden
the tartar in the places where it is disposed to accumulate ; that
is to say, between the teeth and about their necks. Experience
has positively established this fact, and pronounced in favor of
the brush, which, if mounted properly, can be directed against
the sides of the most distant teeth, can penetrate into the inter-
vals which separate them, and rub them in all directions ; espe-
cially since brushes are made in so many forms as at present.
The other means advised to fulfil the duties of the brush are
entirely and properly abandoned ; the sponge, not only because
it produces, in many persons, a sensation so unpleasant as to be
absolutely painful, especially when the teeth have lost some of
their enamel, but because it soon gets hard in flattening upon
the staff" which supports it. The several roots, such as liquorice,
and mallow, because, however prepared they may be, they either
harden or soften, as they are exposed or not to moisture.
To avoid the inconveniences sometimes attributed to brushes,
they ought to be of a force proportioned to the sensibility of the
gums, and to the thickness and hardness of the enamel. It is
also necessary that they be kept in a state of perfect neatness,
and that they be renewed as soon as they begin to wear out,
because they necessarily become harder as the hairs of which
they are formed become shorter. As to the manner of using
them, it consists in rubbing the teeth, before and behind, and
to make the brush pass lightly from top to bottom, so as to
cleanse the interstices as much as possible.
This little operation finished, the mouth must be rinsed again,
to take away the buccal slime which the brush must have de-
PATHOLOGY AND THERAPEUTICS. 127
tachedjOr the residue of the dentifrice if one has been employed.
Simple water, cold or warm, as the season may require, will
suffice for this purpose, but if aromatised liquids be required, as
we have before said, a few drops of Cologne water or some eUxir
will answer.
Finally, we should always remember that after eating we
must use a tooth-pick, to take away the particles of food which
may remain between the teeth. In France, quills are generally
used for this purpose; but in other countries, as in America,
England, Italy and Spain, they use tooth-picks of flexible, tough
wood. These have the advantage that, as their points are not
very sharp, they are not so likely to wound the gum. They are
also made of whalebone, tortoise shell, ivory and bone ; but we
should never use needles, pins, or other metallic bodies. After
using the tooth-pick, which should be done carefully, the mouth
should be immediately rinsed. This is a precaution becoming
common in France, and which we cannot but approve. Whether
this should be done at table or elsewhere, is a question of good
manners which we are not empowered to decide.
Elixirs, Powders and Soft Dentifrices.
As the cleansing of the mouth with water, qualified by a few
drops of aromatic spirituous water, generally answers every
purpose, we have limited ourselves, in the preceding chapter, to
recommending the use of the simplest preparations. But many
persons, in whom caries has already produced ravages, or who
smoke, or whose breath is impure, either from bad constitution
or disease, require more powerful means. This necessity has
led to the exercise of industry, which, unhappily, has too often
resulted in injury to the public health. Therefore, though the
composition of these dentifrices is rather a matter of materia
medica or pharmacy, we may with propriety adopt the common
usage, and give some recipes ; indeed, custom has hitherto per-
mitted dentists to keep an assortment of them, and furnish them
to their patrons. We may only remark, with Gariot, that all
the recipes containfug a crowdof drugs, of analogous, and some-
times incompatible qualities, form fantastic mixtures, which are
12S ANATOMY, ORTUOPEDIA,
not as useful as those obtained by mixing two or three sub-
stances of well known character.
Elixir proper for Morning Use, to Rinse the Mouth.
R Brandy of Guiacum, six ounces,
Vulnerary spirituous water, do.
Essential oil of mint, rose or violet, four drops.
Two or three drops will suffice to aromatise a glass of water.
It suits persons whose mouths are perfectly healthy ; but such
as have bleeding gums or strong breath may substitute the fol-
lowing preparation, to be used in the same way.
R Brandy of Guiac. (prepared,) six ounces,
Camphorated brandy, four grammes.
Essence of mint, six drops.
Essence of cochlearia, six drops,
Essence of rosemary, six drops.
Another Tonic Elixir.
R Ratany root, four ounces.
Spirituous vulnerary water, two litres,
Essential oil of mint, four grammes,
Essential oil of orange peel, six grammes.
Bruise the ratany root, infuse it for eight days in the vulne-
rary water, filter the tincture, and add the essences, previously
dissolved in twenty-four grammes of alcohol.
Elixir knoion as Botet Water.
R Alcohol, at 33° two litres.
Crushed cloves, ^
>each, thirty-two grammes,
Cinnamon, J
Green anise,
Cochineal powder J>cach, sixteen grammes.
Essence of peppermint.
,]■
Dentifrice Powders, (Alibert's.)
R Magnesia, six ounces,
Ked shell, one ounce,
Florence Tris, Hvo ounces,
Supertarlrate of potass, two ounces.
PATHOLOGY AND THERAPEUTICS. 129
Maury^s.
R English magnesia, )
Cremor tartar, J^^^^' °"^ ^'"'^^
Sul. quinine, twenty grammes,
Cochineal, forty-eight grammes.
Essential oil of mint, sixteen grammes,
Essential oil of cinnamon, twelve grammes.
Essential oil of orange, eight grammes,
Muscated and roseated spirit of amber, four grammes.
Messrs. Mihie Edwards and Varasseur.
R Peruvian bark, ")
T.T veach, sixteen grammes,
Magnesia, 3 e »
Cinnamon, four grammes.
Essential oil of cloves, one drop.
This preparation we consider better than the two preceding.
It is particularly good for persons who have spongy relaxed
gums.
Mr. LefoulorCs.
R Equal parts of —
Cochlearia, Mint,
' Horse radish, Pellitory,
Guiacum, Aromatic calamus,
Quinine, Ratany.
It is evident that, in composing his powder, by uniting all the
substances commonly regarded as odontalgic, M. Lefoulon has
rather aimed to satisfy public opinion, than to accomplish any
positive indication. None of these substances can cleanse the
teeth, and the powder is much better qualified to inflame the
mouth than preserve the enamel.
The English, according to a note inserted in the Journal of
Pharmacy and Chemistry, August, 1842, often use the following
preparation :
White chalk, well dried, three grammes,
Camphor, powdered extremely fine, one gramme.
This is intimately mixed and triturated, and preserved in a
flask hermetically sealed.
17
130 ANATOMY, ORTHOPKDIA,
We cannot but think that camphor, however small the quan-
tity, must give the mouth a very unpleasant taste.
There is another powder, which not only whitens the teeth
perfectly, but gives to the lips and gums a fine rose color, which
lasts part of the day. We give it, assured that it no more de-
grades our art to descend to such details, than it does to describe
the manner of making false gums, or to point out the unpleasant
results to the physiognomy of losing one or two teeth.
R Red coral, four ounces,
Sandragon, one ounce,
Fine carmine, five grains.
Lemon peel, twenty grains,
White sugar, sixteen grammes.
The advantages latterly derived fiom chlorine, as a disinfect-
ing and discoloring agent, have led some dentists to introduce
it into dentifrices. In however small quantity it may be, it acts
upon the teeth ; hence it should never be used mor«3 than two
or three times, to take away the deep yellow color which the
teeth of some persons present. M. Taveau has made it an in-
gredient of pastilles, which he recommends to smokers. Here
is the composition of those which Magendie prescribes for the
same purpose :
R Chloride of lime, 8 grammes,
Sugar, 280 grammes,
Starch, 32 grammes,
Gum adraganth, 4 grammes,
Carmine, 15 centigrammes.
Make pastilles of three or four grains ; two to four to be taken
within two hours.
Mr. Magendie advises, besides, for restoring to yellow teeth
their natural whiteness, to rub them with a brush slightly mois-
tened and sprinkled with the following preparation :
R Dry chloride of lime, four grains,
Red coral, eight grammes.
Opiates and Mixtures.
These preparations only differ from the powders, in that they
are blended in a sifflicicnt quantity of syrup or rectified honey
PATHOLOGY AND THERAPEUTICS. 131
to make them soft and pasty. They have no advantage over
the powders, except that they are less liable to be scattered over
the toilet, and are more easily carried about; but they rapidly
deteriorate.
Maury's Formula.
R Best honey, two livres,
Calcined alum, two ounces,
Extract of Peruvian bark, one ounce,
Essential oil of peppermint, sixteen grammes.
Essential oil of cinnamon, sixteen grammes,
Muscated and roseated spirit of amber, eight grammes.
Boil the honey to the loss of a third, color with a little alca-
net, mix the extract of bark, and pass through a fine cloth.
When almost cold, add the alum, and, when quite cold, the
essences.
Upon the plan of these dentifrices is composed the water
which bears our name, (Desirabode water,) and which a minis-
terial circular, dated Nov. 13, 1838, places particularly among
the preparations permitted to be sold, as innoxious.
We may here observe, that the employment of elixirs charged
with resinous and balsamic matters, is preferable to powders
and electuaries. These latter being composed of pulverized
matters are rarely so thoroughly incorporated as to prevent the
inconvenience resulting from their interposition and continuance
between the teeth and the gums.
As most powders which enter into the preparation of denti-
frices, are composed of acid salts, which may rapidly affect the
teeth, a distinguished chemist has suggested to substitute alka-
line salts for them. He has, therefore, under the somewhat far-
fetched name of odontine, presented to the public an electuary,
or rather a soap, composed very simply of the sub. carb. of mag-
nesia and cocoa butler. The academy has been a little too fast,
it seems to us, in patronising this preparation, for the action of
alkalies ought to affect the enamel, if alkaline waters have the
power ascribed to them of dissolving urinary calculi, and if
drinks of the same kind hasten the solution of gouty concretions.
We will also say, that the idea of composing dentifrices with
132 ANATOMY, ORTHOPEDIA,
alkaline salts did not originate with Pelletier nor M. Oudet, who
claims the suggestion, for, before 1836, Dr. Donni had pointed
out Mr. Blondeau, pharmaceutist, as having tried such prepa-
rations.
Whatever be the elements of these preparations, the greatest
pains should be taken to powder well all the hard substances
which compose it, to reduce them to an impalpable powder ; they
should be thoroughly commingled, for if this precaution be not
taken, they will not only be disagreeable, but may injure the
teeth by their physical qualities.
Many persons endeavor to accomplish the end for which these
preparations are intended, by cleansing the teeth by many sim-
ple substances which are commonly at hand, as carbon, soot,
salt and snuflf.
The antiseptic property of charcoal has occasioned it, for a
long time, to be regarded as among the best dentifrices ; its em-
ployment is yet popular, but by no means deserves the prefe-
rence given it; for, if it be only partially powdered, it always
wears the teeth more or less, and, if it be very finely levigated,
it insinuates itself between the external wall of the alveoli and
the gums, to which it lends a violet transparence. We have
sometimes been obliged to detach the gums in order to favor a
hemorrhage, which might wash out the particles. We do not
deny that charcoal has some antiseptic quality, which may ren-
der it useful to certain persons, especially to such as have soft
and bleeding gums.
Table salt cannot be used with perfect safety, because it acts
like other powders ; besides, it is composed of soda and hydro-
chloric acid, whose action cannot be nugatory in the whitening
of the teeth. Its employment also occasions abundant saliva-
tion, which, though useful enough in some circumstances, is
foreign to the end we have in view at present.
As to soot, its employment as dentifrice depends only on the
fact that some persons, misled by the apparent whiteness of the
teeth of sweeps, have supposed that they could obtain similar
results by the use of this substance. But, besides being very
uncleanly, and imparting a very unpleasant taste to the mouth,
it communicates a very yellow or brown tint, which it is almost
PATHOLOGY AND THERAPEUTICS. 133
impossible to remove, and which is not perceived in sweeps,
owing to the habitual blackness of their faces. The following
is a formula of which soot is the basis, and which is lauded by
Dr. E. Kemmerer.
R Powdered wood soot, one ounce,
Powder of strawberry plant, five drachms,
Cologne water, several drops.
What we have said of the inconveniences of soot, also applies
to snutf, whose usefulness is too doubtful to compensate for its
filthiness ; and to Peruvian bark, the tannin of which must, in
the long run, tarnish the teeth. Nevertheless, as the powder of
cinchona enjoys an evident tonic quality, we may sometimes
combine it with other substances, for the purpose of forming a
dentifrice, useful under certain circumstances. For example,
R Powdered charcoal, two ounces,
Peruvian bark, one ounce,
White sugar, two ounces,
'. Oil of mint, one drachm,
Oil of cinnamon, thirty grains,
Muscated and roseated ess. of amber, nine grains.
Sec. 3. — Of Tartar, and the Means of Removing it.
In subjecting the mouth, early, to the rules of cleanliness, and
to different hygienic precautions, which we have described with
a minuteness that will not appear excessive, except to dentists
who have never considered the importance of it. We assuredly
place the teeth in the condition most favorable to their preserva-
tion ; but to obtain their full efficacy, these precautions should
be regular and continued.
If discontinued a short time, the teeth lose their lustre, and be-
come encrusted with a calcareous yellowish matter, called tartar,
a hard coating, which, if left to itself, does not fail to loosen
them, by detaching the gums, introducing itself even to the alveo-
li. It sometimes forms considerable masses, completely encasing
the teeth, and causing them to appear as entirely blended.
Hence we may remark that some have been too rash to con-
clude that the examples reported by the ancients of the teeth
134 ANATOMY, ORTHOPEDIA,
being apparently soldered together, were not correct. This
premature opinion is like many others which modern presump-
tion leads us to entertain with regard to the experience of our
predecessors. Recent facts confirm the account of these appa-
rently conglomerated teeth.
The physiological history and chemical composition of tartar
have long occupied the attention of authors, who have written
upon our art, or upon some of the sciences upon which it is
based. Until lately it has been regarded as a deposit of earthy
salts, precipitated from the saliva by chemical affinities, and de-
posited gradually upon the teeth, where it is attached by the
mucus of the mouth. But M. Serres thinks that it is secreted
by glands contained in the gums, and M. Delabarre regards it
as a noxious exhalation from the mucous membrane which
covers the gums : two opinions originating in love of innova-
tion, rather than assurance of truth. For, if we may overthrow
the one, by remarking that no such glands exist, or if they
do, only in children, who are little subject to tartar, we may re-
ply to the other, with equal force, that the teeth of healthy
people are as subject to it as those of invalids. We must, there-
fore, adhere to the old explanation, although it does not explain
why some are more subject to it than others, although exposed
to the same circumstances.
The chemical analysis of tartar sustains this opinion : being
made Dec. 31, 1825, by the celebrated Vauquelin, aided by
M. Langier, it has shown tartar to be composed
1. Of animal matter, different from that of the bones.
2. Of organic matter.
3. Of phosphate and carbonate of lime.
4. Of a brown matter, resembling oxyd of iron, and formed of
iron and phosphate of magnesia, viz.
Phosphate of lime, 66 parts,
Carb of lime, -----. 9
Phos. of mag. and oxyd of iron, - - - 3
Mucus, ----.-. 14
Water, - - - - . . <j
99
PATHOLOGY AND THERAPEUTICS. 135
We know that the mucus of the saliva (the only part which
can furnish tartar) when burned, will yield much calcareous
phosphate, and a little phosphate of magnesia.
Berzelius, some time before, had found it to contain as follows :
Earthy phosphates, 79 parts,
Undecomposed mucus, - - - - 12.5
Peculiar salivary matter, . . - . l
Animal matter, soluble in hydrochloric acid, 7.5
100.0
But the most important question for us is neither its origin
nor chemical qualities ; we are more concerned about the harm
it does to the teeth, and the gum corresponding to them. We
may first observe that it collects principally upon the six ante-
rior teeth, more on the inferior than superior ; it sometimes ap-
pears only as abundant slime, but ordinarily it forms a hard,
greyish-black body, or a thick yellow crust, which gives the
teeth the appearance of petrified bodies. It is more abundant
upon the side of the mouth which, from any cause, is least used
in mastication, and in the case of persons compelled to live upon
soft food. Smokers are also very liable to it. We have, in our
possession, masses of it of extraordinary size and shape.
The inevitable efiect of the tartar is to prevent the action of
the air upon the teeth, and in certain cases to soften the enamel,
and favor its disappearance. When it thus finds itself in con-
tact with the bony structure, it irritates and inflames it, and pro-
duces a caries, the ravages of which are rapid in proportion to
the denuding of the ivory. Insinuating itself soon between the
neck of the tooth and the gum, it destroys the attachment,
loosens the tooth, and so diseases the gum as to cause it to se-
crete fetid matter.
Tartar, once formed, never disappears spontaneously. In most
cases, it can only be removed by instruments, against which
there is great prejudice. Simple and easy as the operation may
be, it nevertheless demands address and certain precautions,
which are soon learned by practice, which may, however, be
reduced to rule, as we will do as briefly as possible.
The first care the dentist should take, which, indeed, applies
136 ANATOMY, ORTHOPEDIA,
to all his operations, is not to begin until he has disposed at
hand all his instruments and accessories, such as brushes, towels,
warm and cold water, and a flask of elixir. The necessary-
instruments are scalers, gravers and crotchets. They ought to
be very clean, made of fine steel, very highly polished, sharp
and firmly fixed on their handles, so as not to be dismounted
during the operation, which would cause the loss of time, and
fatigue the subject of the operation.
The operating chair should be so heavy as to prevent its tilt-
ing, of such a base as renders it firm, and of a form convenient
for resting the arms, and for affording the head a soft reclining
plane, slightly leaning backwards. It should face the light.
About to begin, the dentist should, as in all similar cases, wash
his hands, so as to remove any disgust which placing his fingers
in the mouth might create. This being done so rapidly as not
to give it the importance of a serious matter, he should place
upon the back of the chair a napkin to cleanse his instruments.
Occupying the right of the patient, but behind her, he passes
the arm around her head, and taking a scaler, proceeds to operate
upon the lower incisors. The lower lip, being abased by the
thumb of the left hand, and forming a fulcrum to the ring fin-
ger of the right hand, he makes the cutting edge of his instru-
ment to pass below the tartar, breaking it in pieces, working
from below upwards, so as to avoid wounding the gum. The
anterior surface being thus cleansed, he uses a thin, flexible
blade, dull at the extremity and passes it between the teeth like
a tooth-pick. He pushes out the accumulated tartar, which, by
its presence, acted as a wedge. The operator then proceeds
to the internal surface, and for this he causes the patient to lean
forward, the lower lip still pushed down by the thumb of the
left hand, but the ring finger of the right being applied to the
crowns of the incisors and canines. Then he removes the tar-
tar, always working from below upwards, either with crotchets
or scalers, ended with thin facets, acute-angled, and with cutting
edges. We may remark that, as it is very diflicult to see the
tartar in this position, it is often necessary to use a small oval
mirror, the case of which is well guarded, and which serves
both to exhibit the parts and push back the tongue.
PATHOLOGY AND TUEKAFKUllCS. 137
To operate on the teeth of the upper jaw, the dentist, always
keeping his left arm around the patient's head, with the index
finger of the left hand lifts the upper lip, the thumb of the right
applying itself to the cutting edge of the tooth next to that to be
cleansed, and the thumb and index holding a sharp scraper,
cutting near the extremity, he raises, breaks and detaches the
tartar from the teeth, causing it to follow the contour of the
gum. The scraper answers for the eight or ten anterior teeth,
but for the large molars the lancet and scaler are preferable. As to
the internal face of the upper teeth, it should be examined, but
it is rarely covered by tartar. The continual movements of the
tongue ordinarily detaches it as soon as formed. If it existed,
the round ended scraper or the crotchet would be the proper
instrument for removing it. When cavities are filled with tar-
tar, unless we prefer to plug them, we should permit it to re-
main, especially if it be in sufficient quantity and is solid enough
to fill the cavity.
It is hardly necessary to observe that during the operation
we should repeatedly cause the patient to rinse her mouth, not
only to facilitate the expulsion of detached tartar, but also to
afford an opportunity to relieve a fatiguing position. We would
not mention the utility of a brush in cleansing the teeth, were
it not necessary to observe that a dentist should have brushes
of various forms ; straight for cleansing the teeth without ; curved
to act upon their inner surface. When the teeth are abundantly
charged with tartar, it is sometimes proper not to cleanse them
completely at a single sitting, and this especially in cold
weather, for the teeth, suddenly deprived of this kind of calca-
reous envelope, acquire a sensibihty which, in nervous subjects,
may be very painful. When there is no urgency, the time of
operation should be fixed when there is little to fear from atmos-
pheric variation. By not taking this precaution, and many
others which good sense indicates, but the details of which
would be tiresome, we may authorize persons whose mouths
have been cleansed to accuse our instruments of causing pains
of which they were altogether innocent.
Finally, to conclude what belongs to the daily care of the
mouth, and the cleansing of the teeth, we may observe, that in
18
138 ANATOMY, OKTHOPEDIA,
Spite of all these precautions, they will sometimes acquire a yel-
low hue, which may be natural to them. We would act very im-
prudently if, in such cases, we should endeavor, by instruments
or any other agency, to procure whitenessandbrilliancy for them;
because, in many cases, we would not succeed, and if we should,
it would be at the expense of the enamel. Let us observe, also,
that this yellow hue is sometimes the proper product of age,
against which all remedies are vain.
Sec. 4. — Of the Means of Remedying Irregularities of Denti-
tion — Vices of Conformation dependent upon the Teeth.
In describing, with all necessary minuteness, the cares neces-
sary for the preservation of the teeth, we have admitted that
they were regularly arranged ; but, whatever care we take to
favor this arrangement, it happens but too frequently that they
persist in taking a wrong direction. Our art is not helpless un-
der such circumstances ; it is only necessary to be well per-
suaded that the success of our means will depend much upon
the circumstances under which they are employed. As to the
nature of these means, they are far from being, as some recent
writings would inculcate, modern discoveries. There is not a
dentist who has practiced for thirty years, who has not employed,
every day, the very means now in use; and if some practiciens
seem to make this a subject of particular attention, this is rather
the result of enlightened public opinion, which better appre-
ciates these things, than of anything they have added to former
knowledge.
The irregularity of the teeth depends either upon their devia-
tion, their formation or implantation. Each of these vices may
be carried to the extent of true deformity. Let us first examine
vices of deviation.
These irregularities are commonly known as obliquities. The
obliquity may be forward, backward, laterally, or by rotation,
according as the teeth which constitute it are directed outward
or inward, mount upon the faces of their neighbors, or have
undergone such a movement that one of their sides presents
forward, and another posteriorly.
PATHOLOGY AND THERAPEUTICS. 139
The primitive or temporary teeth rarely exhibit these devia-
tions, and when they exist, they are generally so little impor-
tant as to be unworthy of attention. As to the secondary teeth,
the incisors and canines are most frequently thrown out of their
proper place, which is readily enough explained by the fact that
their roots being single, and occupying less space in the alveo-
lar border than their crown does beyond it, they are more ex-
posed to forces which may be brought to bear upon them.
It must not be supposed that any great force is necessary for
this purpose. It only requires a slight default of antagonism
between two powers in the midst of which the teeth are placed,
that is to say, between the lips in front and the tongue behind.
Do we not perceive that, in almost all cases of hare-lip, the teeth
corresponding to the fissure, throw themselves forward ; and that
the operation which cures this deformity also replaces the teeth ?
This is an important fact, which goes far to enlighten us upon
the choice of means proper for replacement.
If we study the causes which produce these deviations, we
find it sometimes in an organic malady of the alveolar border ;
but the more common cause, as we have already said, is the
defect of relation between the size of the teeth and the space
they ought to occupy ; the tardy shedding of some primitive
tooth ; the presence of a tooth trespassing upon the space pro-
per to another ; finally, the existence of a supernumerary tooth,
which we have called a surplus tooth.
Art has two kinds of means of remedying obliquity : the
first act slowly, continuously, and are incapable of occasioning
the least accident, or even the slightest pain : the others, on the
contrary, act promptly but painfully, whence they would be
abandoned, even if there were not other peculiar inconveniences
attending them.
The first of these expedients consists in bringing back the
distorted tooth into its proper place, by the aid of traction exer-
cised upon it by ligatures, which have their point d'appui upon
the neighboring teeth ; but two conditions are necessary : there
must be sufficient space to receive the tooth, and the tooth which
forms the basis of support to the traction must be more firmly
fixed than the one to be moved.
140 ANATOniY, ORTHOPEDIA,
As many persons doubt the success of this proceeding, it is
proper to observe, that the tooth to be removed does not repre-
sent an inert force to be overcome, but an active force, the direc-
tion of which should be changed. Let us reflect upon the fa-
ciUty with which the most firmly resisting of our tissues yield
to the action of slight forces when long continued ; and we will
perceive that there are few cases in which a simple lever, skil-
fully used and firmly fixed, will not suffice, especially in young
subjects, to replace a tooth, however distorted it may be. Every
thing depends, in these cases, upon the address and judgment
of the operator.
But should we have threads alone, reckoning upon their own
elasticity, or only use them as means of attachment? We be-
lieve that threads have rarely the power supposed, and expe-
rience shows that they are fraught with great inconvenience.
In the first place, they loosen the teeth around which they are
thrown for support ; and again, they strip these as well as those
to be moved, and act too near the neck.
We know that, to obviate the loosening of the supporting
teeth, those are chosen which have stronger roots than the
irregular teeth ; and that to prevent the ligature from gliding
under the gums, use is made of a small hook, one of the curves
of which fits upon the cutting edge of the tooth, while the other
holds back the ligature. But, on the one hand, the form of the
roots is too variable to permit us always to calculate upon their
respective forces; and if, on the other hand, the hooks applied
upon the teeth prevent the thread from slipping, they are means
which always impede the action of these last, and hinder it from
being direct.
Thus, then, if we would act with certainty, we ought rarely
to confine ourselves simply to ligatures. There being a certain
resistance to overcome, as must be the case in patients somewhat
advanced in age, we may augment the power of the ligatures
by combining their action with those of different apparatus,
commonly described under the name of plates or bands. These
are a kind of metallic springs, narrow and thin, adapted to the
contour of the alveolar border, and applied in front or behind
this border, according as the irregular tooth has deviated forward
PATHOLOGY AND THERAPRUTICS, 141
or backward ; but better still, a double band, which gives to the
thread a surer support, by hindering it from gliding upon the
crown of the tooth, especially towards the neck. In order to
explain their action and the mode of applying them, we will
cite an example : Let us suppose an incisor thrown forward
and having space enough to permit it to be reduced into line.
We take the mould of the defective dental arch, as it will be
described in the ^^prothesis." Then, upon the posterior and
anterior faces of the teeth, we adapt a bandelette of gold, some-
what less wide than the height of the teeth, but touching them
all in the direction of the alveolar border, terminating at each of
its extremities by a kind of bracelet, or better still by a true
cap, which envelopes the two last molars, upon which we
wish to take a firm support. Before applying this little appara-
tus, we pierce each bandelette with two holes in the same hori-
zontal direction, and precisely at the point corresponding to the
irregular or oblique tooth. Finally, when it is applied, we pass
through the holes a thread of raw silk waxed, or of platina, and
twist them round the tooth to be replaced.
This apparatus, which is the only one we employ, as it is
much more sure than the simple thread, has this advantage,
that its action is constant. This continuousness results from
the incessant action of the spring reacting upon the thread. The
power may be increased by so arranging the spring that it shall
not touch the teeth which form the sides of the vacant space to
be filled by the tooth to be retained. We have cited the sim-
plest case in which the band is applied ; but it is easy to per-
ceive that it might be used upon several teeth as easily as upon
one. It is only necessary, in complicated cases, to pierce the
bandeau with as many holes, and pass through as many liga-
tures as there are irregular teeth.
Whatever modern authors may say of the means we have
described, claiming it as their own invention, and supposing,
upon the ground of some modifications, that they have ''resolved
a problem never before thought of," it is nevertheless true, that
it was known to the ancients. A detailed description of it may
be found in Fauchard, and if our predecessors have not derived
as much benefit from it as ourselves, it was because they did
142 ANATOMY, ORTHOPEDIA,
not avail themselves of firm points d'appui, a first condition in
all apparatus of replacement.
When one has become'familiar with the mode of applying
bandeaux, formerly called plates, and which are nothing more
than springs, he will perceive that they are only applicable to
anterior and posterior displacements ; but generally simple liga-
tures are used to correct lateral and rotated obliquities. In the
first case, the thread is firmly fixed upon the last or even the
two last molars of the side opposed to the deviated tooth, and
we tie it upon the latter, causing it to pass in front of the neigh-
boring teeth, when the tooth presents inwardly, and vice versa.
This direction of the ligature exercises less traction between
the two lines which the tooth must traverse in order to reach its
place, for it is evident that if, in a case of inward lateral obliquity,
of an incisor for instance, the thread departed from the inward
face of the molars, it would only draw backwards, but not into
the vacant space to be occupied.
As to rotary deviations, they are generally corrected by sur-
rounding the tooth with a strong silken thread, one of the ends
of which is carried inwards, the other outwards, to be fixed upon
the last molars. As these teeth, especially if they are incisors,
leave sufficient scope, by the very fact of their movement, to the
means to be employed for their restoration, we surround them
with a little ring, which embraces them exactly, and bears in
front and behind a small hook, into which the thread is received
to go to fix itself upon the molars of each side, either directly or
by the intervention of a little cap placed upon these latter, or a
small ring upon which the thread may be tied.
Generally, by these and similar means, we may succeed, in
less than a month, in restoring a tooth to its natural place. In
the course of treatment, the ligature must be changed and re-
adjusted every three or four days. When the desired end has
been obtained, we sustain the tooth for one or two months, or
more, by means of a smaller ligature or a gold thread, until the
alveolar border shall have acquired sufficient firmness to main-
tain the tooth in the direction given to it ; but what is yet bet-
ter is to cause the patient to wear at night a kind of metallic cap-
sule, fitting exactly upon the teeth, and enclosing not only the
restored tooth, but those surrounding it.
Pathology and therapeutics. 143
We may perceive the importance of this, if we remember the
intensity with which the jaws are sometimes clenched at night.
We have seen this so strong as to displace artificial pieces, when
inconveniently arranged. It is well to take another mould of
the mouth after the success of an operation of this kind, as, by
the comparison of this with the previous mould, we may the
better judge of the result in all its extent.
We have remarked that besides ligatures there was another
way to restore a deviated tooth to its natural direction. This
means is incomplete luxation. As it is not without danger, it
should never be tried except when the inefficiency of ligatures is
well established, as in the case of an individual twenty or thirty
years old, in whose case one or two teeth should project within
the alveolar border. If the operator concludes that the space des-
tined for the distorted tooth is not large enough to receive it, he
will file away the adjacent teeth and the displaced tooth, until
the necessary size is obtained, when he will luxate the latter,
and restore it to its proper position.
Pincers will ordinarily suffice for this purpose ; but, in order
to success, it should be done with all possible care, and all
efibrt should cease as soon as it is brought to the level of
the others. It is then prudent to preserve it in its new place
by ligatures. Some weeks will suffice, it is said, for the alveolar
border to adapt itself intimately and render it as firm as before.
But, we repeat it, this manoeuvre, which properly belongs to
surgery, is not only of doubtful efficacy, but may be attended
with disastrous consequences. It is indispensable, indeed, that
in practising it, even with all possible care, we may not only
break and tear the gums, tear the alveolo-dental periosteum,
fi-acture the alveoli, but even break the tooth. Therefore, we
have never undertaken it, and we advise all young practitioners
to avoid it, or never attempt it until they have well balanced the
chances.
We have all along supposed either that the space proper to
the tooth remained unoccupied, or that room could be made by
extracting a tooth. When, however, there is nearly sufficient
space, it is not necessary to make such a sacrifice. The end
can be obtained by filing slightly the sides of the displaced tooth
or of those between which it is placed, as we have already said.
144 ANATOMY, ORTHUPEDI.v,
CH A PTER IV.
PATHOLOGY AND THERAPEUTICS.
Of authors who have written on specialities on our art, some,
as Maury, holding no account of the relations of organization
and of the end which unites the dental bone and its central
ganglion, content themselves with dividing the diseases of the
teeth into those which relate to their hard parts and those which
effect their soft parts ,- whilst others, as Lefoulon, having no very-
just idea of that which they ought to understand as diseases^
have added to the number of those of their teeth, simple anoma-
lies of form and of arrangement. More logical in this respect
than those, we have arranged the changes of the organs, which
we shall now treat of into three distinct classes.
The first includes the vital or pathological changes properly
so called, which are, injuries of the follicles ; erosion or atrophy
of the teeth; discoloration and decomposition of the enamel;,
consumption of the roots ; caries and its different varieties ; exos-
tosis and the spinal ventosis ; softening ; inflammation ; fun-
gosity ; ossification even of the dental pulp, and finally the differ-
ent nervous affections of the teeth.
The second comprehends, on the contrary, injuries purely
physical, as the wearing away, cracking and fracture of the
teeth ; their loosening, fluxation and denudation.
Finally we have arranged in the third class the diseases of the
auxiliaries of the teeth-, either the diseases of the gums of an in-
flammatory nature, or the diseases of the alveoli.
VITAL OR PATHOLOGICAL CHANGES.
Diseases of the Follicles.
For every attentive practitioner to return to the first origin of
diseases, it is manifest that a sufficient number which effect the
teeth can be referred to other causes than the disorders to which
their follicles have been exposed. This circumstance has ne-
cessarily been overlooked a long time ; for, to place it beyond
doubt, two things are necessary which are rarely presented;
PATHOLOGY AND THERAPEUTICS. 145
either that the alveoli were open when they contained only the
follicles, or that later, when it is possible to penetrate the scalpel
with the hand into the interior of the gums, we will find there
the follicles which precisely at this period have disappeared.
Oudet is believed to be one of the dentists who were first oc-
cupied with this important subject ; for, in a treatise relating to
this question, he relates as something new that, in many cases
where the crown of the tooth still remained in its follicle, it ofier-
ed signs of atrophy, he has found also many points of the in-
ternal membrane much redder than in its normal state.
We have proven this fact in later years and in many instances ;
from thence we desire this opinion, that we publish as a funda-
mental maxim, that a great number of changes to which the
teeth are subjected are dependent upon an inflammation which
at an earlier period has aflfected the internal membrane of the
follicle.
A circumstance which goes still more to strengthen this opin-
ion is, that we have many times met follicles whose cavities con-
tained a purulent, yellow and thick matter, which could only
have been the result of an inflammatory work, whose efl'ects
have inevitably made us sensible ofa germ within, whatever may
be the theory that we adopt to explain the formation of this £>erm.
It is even possible, in analyzing with care the writings of
many ancient authors, Jourdain* and Bourdet,t for example to
find some traces, if not of the express opinion that certain
changes of the teeth had primitively taken place in the follicles
at least of an opinion nearly analogous ; for they admit that many
changes of the enamel depend upon the vicious qualities of the
fluid exhaled by the internal membrane. Jourdain quotes to this
eflect, many observations made upon individuals who have been
attacked, either by putrid fevers, or varioloidal and scorbutica!
aflections, and among whom he has discovered remarkable
changes in the fluid of the follicles.
As one perceives, these observations are not altogether unim-
* Treatise upon the Diseases and Surgical Operations of the Mouth. 2
vols, in 8, 1756.
t Researches and Observations upon every part of the Art of Dentistry 2
vols, in 12, 1756. **
19
146 ANATOMY, ORTHOPEDIA,
portaiit, yet one must not be too positive, still they are no less
important, when one considers, in effect, the manifest correla-
tiveness which exists between many changes of the teeth and
the different diseases which have exerted a troublesome influ-
ence upon the development of the follicles, we cannot refuse to
believe that the different secretions which have a place in the
interior of them, and which preside at the formation of the teeth,
exert a powerful influence upon the manner of which these den-
tal bones will be organized. The same dependance in which
we find the other fluids of the organization bear to these secretory
organs, we find between the tooth and its follicle; in such a
manner that the least cause which troubles the functions of the
latter must necessarily be reproduced under the configuration of
the first. This is a general law to w^hich the teeth have never
made a single exception.
Let us add to that, that the teeth once formed, and deprived in
part if not altogether, of the vasculary elements., would them-
selves only become the seat of a weak nutritive process, and con-
sequently pathological ; we hence perceive the great importance
of these organs which have immediately contributed or only pre-
sided over their formation, and which constitute the natural
bonds by which they were held dependent upon the organiza-
tion of which they have received all of their injurious influences.
Also, the ill health of parents, the diseases which attacked the
mother during pregnancy or lactation, all diseases to the foetus
or child is subjected during the first or second dentition, do they
effect the teeth only in acting upon their follicles.
As all these diseases might have a different degree of strength
and intensity, as they might attack separately or at the same
time the two secretory organs which enter into the composition
of the follicle, the morbid effects which result ought consequently
to vary. Thus, often, without presenting any sensible change,
the texture of the teeth will become extremely delicate and
weak, a disposition which is the principal cause of a premature
destruction. At another time, we discover more or less injuries
upon the surface of the enamel, injuries which are perceived at
the time of the formation of the teeth, and showing that the in-
ternal membrane of the follicles had been diseased in several
PATHOLOGY AND THERAPEUTICif;. 147
parts of its extent; finally, in some instances, the ivory will be
the seat of many changes which depend very evidently upon
diseases to which the functions of the pulp have been exposed.
This truth once well established as a fundamental indication,
let us examine successively the different diseases of the teeth,
following for their description the eminently methodical order
that we have heretofore adopted.
Congenital Defects of the Enamel.
Erosion or Atrophy. — If we were always obliged in order to
form an exact idea of things, to search for the literal sense of
words employed by us to designate them, we ought surely to
understand by erosion only a change of the teeth caused by the
action of an erosive agent, as an ulcer, and acid, and large file,
and by that oi atrophy, their defect of development, as we have
before said ; but dentists, for the most part such bad ety-
mologists, have commonly described under these two names, a
change of teeth which depends upon a defect in the secretion of
enamel.
This affection is always congenital, that is to say, that it ex-
periences no change after the formation of the crown, but is the
constant result of a defective secretion of the internal membrane
of the follicle, a little before birth. It then seems that nature
has not sufficient force to form a sufficient secretion of enamel,
and that it has been arrested in this work by causes difficult to
be understood. The forms under which this change presents
itself are very variable ; we are able, however, to reduce them to
three principal ones.
The first variety of atrophy of the enamel affects only the sur-
face of this cortical envelope. It consists in spots of a milk
white or of a yellow more or less deep, sometimes black. The
spots, often irregular, do not injure the brightness of the enamel ;
they remain stationary, but nothing can make them disappear.
The second variety, the most common, consists in small irre-
gular indentations, like pricks scattered irregularly here and
there, variable in number, upon the different parts of the free
surface of the teeth. Ordinarily very small, superficial, these
148 ANATOMY, ORTfTOPRDiA,
indentations form a rough surface which is a true erosion. They
have often considerable extent and present facets ; sometimes
these furrows or depressions are circular in the form of gutters,
which traverse the contour of the crown ; or finally these trans-
verse sinuosities are united or separated by projecting lines.
As to the third variety of atrophy^ it differs entirely from the
preceding, in this respect, it affects all the dental substance, but
especially the enamel. In rigorous language, it merits only the
name of atrophy; for it is a kind of modification, a sort of wasting.
In this variety, there is a loss of substance more or less great
which occupies most commonly the centre of the external face
of the crown of the exterior teeth or the triturating surface of the
large molars. Often, then, the free extremity of the teeth is
almost entirely deprived of enamel to a certain height, as if it
had been plunged in a corrosive liquid. The incisors offer deep
and irregular dentings, the canines are very long. The diseas-
ed tooth remains all entire by a decree of development ; some-
times it is completely deprived of one of its constituent parts ; so
much so that its crown is reduced to two-thirds of its volume, so
much so that it offers a circular depression, and even a true cavity.
We have also remarked, that the roots of teeth thus disfigured
offer similar sinuosities, projecting and circular lines, and that
they were knotty and very short.
Atrophy is idiopathic or symptomatic. We meet the first
among subjects of excellent health who have never been sick.
It evidently depends upon local causes which have troubled the
functions of the follicular membrane. The second is common
among individuals who are in bad health, of a lymphatic and
scrofulous constitution. The varioloid, scarlet fever, measles
and different gastro-intestinal inflammations appear to have a
powerful influence upon its development. Thus, whilst idiopa-
thic atrophy affects only a small number of teeth and appears
only in few parts, sympto?jiatic attack ordinarily most of the teeth
and causes great disorders.
As the different changes of which we are speaking might have
a very variable intensity and duration, the depth, extent and
number of lines traced by atrophy ought also to vary. More-
over they do not occupy, when many teeth are aflfected the same
PATHOLOGY AND THERAPRTJTTCS. 149
place upon the crown ; they might occupy the cutting edge of
the second incisors and the triturating surface of the first mo-
lars ; and thus in order. These differences evidently answer to
the order of succession that agrees with the formation of the
teeth, and might even seem to establish, in a manner sufficiently
precise, the time at which the subject had been attacked with
some serious disease. If, for example, the incisors are only af-
fected, we are authorized to presume that the person had been
diseased towards the first or second year ; if they are, on the
contrary, the small or the two permanent molars, the disease
might have existed at the fourth or fifth year, a period at which
the fourth and even often the six anterior permanent teeth have
already their crowns entirely enamelled.
It has long since been observed that the milk teeth are much
less liable to be affected with atrophy than the permanent ; but
they are affected by it, they are a sufficient number whose de-
velopment is prevented by it. As to the permanent teeth, those
which carry most commonly traces of this change, are the inci-
sors and the first large permanent molars ; the second large mo-
lars and the small of the same name, or bicuspides, next come
under this relation.
We have until the present spoken only of erosion in the sense
that most authors give to this change, they attribute it nearly
always to a defective secretion of enamel. But erosion exists
not less as a disease affecting this body consecutive to its forma-
tion, or, to be better understood, we say that independently of
congenital defects of the enamel of the teeth, they might
still, long after their eruption, find themselves at one instant
deprived in many parts of their crown, of their vitrous en-
velope. This kind of erosion, that we shall name consecutive, in
opposition to the first, is very common among young subjects
exposed to affections of the digestive organs. Do the mucous
fluids, in the midst of which the teeth bathe in these diseases ac-
quire corrosive qualities sufficiently marked to explain its de-
velopment ? It is this that we are ignorant of, but the return of
minds to the study so long neglected, will permit us to see the
solution of this question. Let us remark, nevertheless, that we
have often met consecutive erosion upon subjects attacked by
150 ANATOMY, ORTHOPEDIA,
diseases occasioned by the presence of intestinal worms ; we had
observed, some time since, an example of it upon a young girl
attacked with epileptiform hysteria, and whose teeth had been
perfectly healthy until the time of this affection.
When the depressions which we have remarked upon the
enamel are light and very numerous, and this presents its natu-
ral color, they present really no deepness. But when they
penetrate so deeply as to impair or deprive the tooth of a part of
its enamelled covering, or where one part of the crown is de-
stroyed, they constitute a grievous state, because they are the
forerunners of decay.
As it is so difficult to make the different changes resulting
from dental atrophy disappear, it is principally their causes that
we should attack and combat with, either to prevent them or
stop their progress. This indication, as we perceive, cannot be
remedied, excepting by the observance of the rules of hygiene,
of those whose end is to prepare a perfect set of teeth. If the
change depends upon a general affection, we should direct all
the efforts of therapeutics to the treatment of this last. In some
circumstances, nevertheless, the aid of surgery would undoubt-
edly be advantageous. Thus, where the depressions occupy
the free extremity of the crowns of the anterior teeth, they can
be made to disappear by use of the file, being always careful
not to wear away too deeply the tissue of ivory. If the crown
is excavated in such a manner as to present a cavity of a certain
extent, like that which generally happens to the large molars,
the caries can be prevented by filling it with gold or silver leaf,
or other substances, after having first cauterised the base.
Decomposition of Enamel.
The enamel can yet present changes of another nature, whose
origin relates equally to follicular injuries. Amongst these
changes, there is one very common — one which merits our
attention, and which we have named, with Maury, decomposi-
tion of enamel. It manifests itself by brown or black spots,
which develope themselves upon the anterior face or sides of
the crown. These spots often extend to the internal face of the
PATHOLOGY AND THERAPEUTICS. 151
enamel, which, however, in most cases, preserves its lustre.
Although in general it takes its origin in the rudimentary tis-
sues, yet this alteration may depend upon too great pressure, or
upon the great nearness of dental caries ; but, in this case, the
tooth is not painful, and its alteration ceases mostly with the
destruction of the mechanical cause which produced it.
In another kind of decomposition of enamel, we observe the
spots to be of an unpolished white, circumscribed, situated
ordinarily on the anterior face of the incisors, and very often
near the external part of the neck of the inferior molars. Their
color becomes yellow by degrees, and disappears with the lustre
of the enamel. This possesses a delicate and brittle texture,
which causes it to break into small particles, even to its com-
plete destruction, with the least effort. In this case, the teeth
are sensible to cold, to heat, and even to the contact with all
strange bodies, and become easily encrusted with buccal acid
and tartar. As a habitual prelude of caries, this variety of de-
composition affects, in preference, persons of a bilious tempera-
ment, convalescing from long diseases, in the course of which
they have been frequently salivated. If the affection is light,
it heals itself often, by the re-establishment of health, assisted,
by all means, with habitual cleanliness.
Discoloration of Enamel.
The teeth offer, under the relation of color, certain differences,
which constantly coincide with certain general dispositions of
individuals, and often, in this respect, furnish important indica-
tions. In general, those of first dentition are of a brilliant milk-
white ; but among adults the shading of color is very variable ;
we can, however, reduce them to three principal ones. The
unpolished white, approaching to yellow, is found principally
among subjects enjoying excellent health ; they are ordinarily
short, in regard to the stature and strength of the individual.
Grey- white denotes, on the contrary, a quality less advantageous.
But, of all the colors of the teeth, the least to be desired is
blue-white. They are most ordinarily found among young
subjects, (especially young girls,) who are affected with diseases
152 ANATOMY, ORTHOPEDIA,
of the chest, principally those that characterise a development
of tubercles upon the lungs; subjects that are vulgarly desig-
nated by the name oi consumptive, and who very rarely possess
the advantage of preserving their teeth perfect until tlie end of
their lives. This observation has already been made by Blu-
menbach and Camper; it follows that the azure tint of the teeth
will be the manifest symptom of an alteration existing in the
ivory of the teeth. Thus it is, in a great number of chlorotics,
the teeth take, after the first period of the disease, the color of
brick-yellow, which we always regard as the sign of a fatal
termination.*
One perceives, then, how all the relative details to the diver-
sity of the tint of the teeth, and to the appreciation of causes
after diseases which might have occasioned it, ought to be of
importance to the attentive physician, since their simple inspec-
tion affords not only a knowledge of their length, but of the
constitution of the individual, and of the different diseases he
might either have been affected with, or more particularly ex-
posed to.
How, can it be asked, do these differences of color and
quality belong to the teeth ? This question has not, certainly,
until now, obtained the attention that it merits. All that which
is believed to be known, and which contents us, is that these
differences belong to the chemical composition of their organic
substance. Thus, those whose tissue is of deep yellow, and
scarcely impressible, might have a superabundance of calcareous
salts ; those, on the contrary, which are distinguished by their
whiteness and sensibility, and which are tender and delicate,
might owe these qualities to a predominance of animal matter.
These two fundamental differences, whose existence is little
contested, are met in two kinds of constitution and temperament,
altogether opposite, and evidently belong to the general dispo-
sitions of the economy.
* Begin has also reported to the Academy of Medicine, that, in this case,
the teeth present sometimes a bluish color, which not only occupies their
surface, but even penetrates into the interior of the dental tissue; this color-
ing became so deep that the boys of the amphitheatre complained of not
being able to sell them.
PATHOLOGV AND THERAPEUTICS. 163
From thence it is perceived how it is difficult in admitting
that the discoloration of the teeth, in a great number of cases,
may be the result of a pathological state, to trace to its relative
exact therapeutic rules. This discoloration, being ordinarily
effected under the influence of a general change in the organism,
our course should be always subordinate to the treatment of
this change. Thus, when in the course of a disease, the teeth
have taken an unusual color, we see them take their natural
color when the affection ceases, especially when it is of short
duration. But in the mean time, this change or return of color
seldom takes place where the disease is long, or after the age of
forty, or even of thirty-five years, a period when the vitality of
the teeth has necessarily lost a great part of its reactionary force,
All attempt, in this case, will be, as we have already said it,
chance with an imprudent or inexperienced dentist.
We except, by all means, from this anormal coloration, which
belongs to a general state of economy, certain greyish or yellow-
ish spots, which form often near the neck of the teeth, without
having anything in common with tartar. These spots have no
thickness upon the enamel, and ought to be observed.
Consu7nption of the Roots.
This affection is rarely idiopathic ; for it is nearly always oc-
casioned by an alteration of the envelopes of the roots, as of the
periosteum, of the alveolar membrane, or surrounding soft parts,
which, by their inflammation, and consequent suppuration,
cease to adhere to the teeth, which they reduce to the state
of a foreign body, whose destruction becomes inevitable. This
disease is developed in various conditions of age and health j
sometimes among subjects from the age of forty to fifty years ;
among those, principally, who, at that age, experience a sud-
den change of constitution ; sometimes, on the contrary, among
young men ; but now and then among females newly brought
to bed.
This disease, which is not confined to a single tooth, but
extends sometimes to many, and even to the alveolar border
of both jaws, although local in its origin, can, as we perceive,
20
154 ANATOMY, ORTHOPEDIA,
acquire a troublesome importance. It is natural to think
that the use of topical tonics, even a few astringents, in modi-
fying the vitality of diseased tissues, ought, after the inflam-
matory period, oppose the loosening of the tooth and prevent
its consumption, or at least the atrophy of its root. Expe-
rience unfortunately does not always accord with this indica-
tion of the theory. We are sometimes obliged to abate a disease,
by applying a button of caustic upon the principal seat of the
disease; and if this means does not succeed, it is necessary to
extract the tooth around which there is the most inflammation.
This sacrifice ought even to extend to many, if the disease has
reached the whole of one jaw or different points of both ;
and this had better be done too soon than too late ; the conse-
quences, however, must be weighed well first.
Dental Caries and its Varieties.
We designate under the name of caries^ that change so com-
mon to the teeth, which consists in a gradual destruction of a
part or of the loliole of their substance.
Is this change of nature absolutely identical with that which
afiects the bones in general? It was believed so a long time,
and this opinion was inferred by the analogy which seems to
exist between the osseous tissue and that of the teeth. But the
opinion at the present time is, as we have already advanced and
demonstrated at the commencement of this work, that the teeth
constitute in the economy a kind of substance, a part of whose
intimate composition is certainly far from being exactly that of
bone ; for the enamel which forms, as every one knows, the
most exterior layer, contains neither fibrine nor albumen : water
alone is found there, in combination with phosphate and carbo-
nate of chalk ; and if some animal parts enter into the tissue of
the subjacent layers, they are so mingled with these two salts
that they do not absolutely perform any contractility, and are
endowed only with a feeble irritability.
The absence of nerves and visible vessels in the ivory, the
kind independent of the teeth, although they partake directly of
life^ do not permit us to establish between them and the bones
PATHOLOGY AND THERAPEUTICS. 165
any exact relation, it is natural to suppose that there might be
between the morbid affection which is the object of this article,
and the caries of the bones, as much difference as exists between
the tissue of these two parts.* This supposition admitted, it is
no less just to avow tliat Uiese two changes have, for a common
characteristic a softening and decomposing of the earthy parts
which enter into the substance of the organs that they affect.
There are few diseases which, since the time of Hippocrates,
may become the object of more researches, and the subject of
more writings, than dental caries ; and, however, in spite of
these enterprising works, mostly made by celebrated physi-
cians, able observers, it is still difficult to form an exact idea of
the pathological phenomena which constitutes it. This difficulty
happens principally from this, that authors have confounded,
under the common name of canes, diseases that are important
to be distinguished, because there exists between them remarka-
ble shades, under the relation of causes, of the progress, of the
final results, and, consequently, under that of the treatment,
which forms here the essential point.
Of these diseases, designated under the general name of caries^
some are entirely produced by local agents, and consist in the
chemical destruction of the dental substance; destruction which
is made from without mwardly, and of which we will speak
hereafter; others are caused by a disease of the pulp, or a primi-
tive defect of the ivory, and develope themselves spontaneously
from within outwardly. This last kind we designate more par-
ticularly under the name of caries.
* At the same time when we give the passage for print, we take notice of
the memoir that Nasmyth, member of the College of Surgeons at London,
has submitted to the institute, and in which he says that the teeth offer not
a fhrous disposition, as it has been believed until the present, but porous
and cellular. This fact, which appears very important at first, destroys com-
pletely the difference which exists between the bones and the teeth. It
shows only that they have a common character besides to add to those
which reside in the presence of calcareous salts as a base for one another.
But the identity of their mode of development does not seem sufficient to
establish the fact that they are upon the same line in that respect. (See the
exact account of the meeting of the Institute of December 5th, 1842.)
156 ANATOMY, ORTHOPEDIA.
Whatever may be the import of the denomination, the dis-
ease is so common, that few persons, even in the best of health,
are exempt from it. It attacks indiscriminately children,
young men, adults, and even spares not old men. It is natu-
ral to suppose that organs which, during the time of their
formation, have been submitted to the influence of general
causes, which have acted upon the whole constitution of the
individual, ought necessarily to undergo, at a later time, the
effects of them.
That consequence, that we have already treated of, in speaking
of the diseases of the follicles, and to which the most simple
observation conducts, we explain, because we daily see it in
individuals born full of vigor, whose health has never been im-
paired, and who, in the mean time, have had, from their youth,
very bad teeth, whilst others, of a weak and languid constitu-
tion, have very beautiful and strong ones. It would be, then,
as irrational to endeavor to trace all the causes of caries to the
time of the formation of the teeth, as to disavowal] the influence
that the diseases of the first age might exert upon the develop-
ment of caries with which the teeth are attacked even at an
advanced period of life.
Caries being the most frequent disease of the teeth, a disease
whose treatment and results form the most important part of
our calling, we should study it with great care. In order to
omit nothing useful, let us examine it successively, under the
relation of its causes, of its symptoms and its course, of its seat,
its diagnosis, its prognosis, and its treatment.
Firsts Causes. — Amongst authors who have studied caries, in
explaining the causes of this singular and often exclusive dis-
ease in its course, some have admitted only internal ones ; others,
on the contrary, but external ones. But the greatest number,
at the present time, believe they result from both, and most
generally from simultaneous action. Hunter* thinks that it
is hereditary, and regards it as a kind of mortification or ne-
crosis of the dental substance. When we reflect, in effect, upon
*J^atural History of the Teeth and their Diseases. London, 1771. Trans-
lated in Latin, 1773; German, 1780.
PATHOLOGY AND THERAPEUTICS. 157
the frequency of caries in the members of the same family, we
are not far from admitting this disposition. Fox* beheves it
always is a defect in the primitive formation of the teeth. This
opinion is corroborated by this fact, that we have ah-eady estab-
hshed, knowing that the disorders of caries are confined often to
teeth which formed during the course of a certain period of den-
tition. It is to this kind of aheration that it is necessary to refer
constitutional caries that we meet so often among members of
certain families, that have either caused primitive and original
disposition, or that they depend upon local or accidental in-
fluences.
Caries, we have said, does not escape any age ; but habitual
observation declares that women and young men are more ex-
posed to them than middle aged and old men. They seem en-
demic in certain countries, particularly in humid and marshy dis-
tricts, or neighborhoods bordering on the sea. Holland offers a
remarkable example of this.f It is, then, in the influence of gene-
ral agents, which modify all the organism, that it is necessary
to seek for the first causes of caries. It is thus that the teeth,
whose texture is weak and soft, which are of a milk-white, of a
dull blue, and consequently defective, carry in themselves the
sources of their premature destruction. There is in them a
number of organic or accidental diseases, as scrofulous affections,
tetters, lympliatic gout, severe or chronic inflammations, ner-
vous diseases, too rapid growth, which are as many general
causes, under the influence of which caries developes itself.
Although many of the causes that we have shown as capable
alone, by their powerful influence, of affecting the composition
of the ivory, to involve the teeth, as soon as they are formed, in
inevitable ruin, it cannot be denied that, in a great number of
* Tlie History and Treatment of the Diseases of the Teeth, Gums, ^c.
London, 1806.
t"We have two very striking examples of this in France; the inhabi-
tants of the countries of Caux, and those of the environs of Bauvais in
Picardy, have, for the most part, the two central incisors of the superior
maxillary decayed; after these the laterals are affected; and thus, in turn,
in such a manner, that at the age of thirty years they have lost the greatest
part of their teeth." (Rosseau : work quoted.)
158 ANATOMY, ORTHOPEDIA,
cases, they exist only as predisposants, and have effect only by
the train of local circumstances, or, to speak plainer, actual ones.
Is it not observed, in truth, every day, that caries destroys with
promptitude teeth which have scarcely appeared through their
alveoli, whilst among other subjects, as unfavorably placed, it
commences a long time before manifesting itself, or appears only
to occasion accidental influences, perfectly characterised.
Amongst the local causes which produce caries, it is necessary
to place those bodies which, being placed in contact with
the teeth, are capable of exercising upon theni an unfavorable
effect, by their temperature or chemical action. The influence
of heat upon them is most evident, as we have already observed,
in the chapter devoted to hygiene. Likewise, the use of warm
drinks, among certain nations, seems to us eminently pernicious,
as those in England, Holland, and as we have even observed
frequently in Russia, where wealthy and opulent men lose their
teeth in early years, whilst their domestics preserve theirs per-
fect to an advanced age.
Many authors also have thought cold to be one very powerful
cause of dental caries. If this assertion is not completely false,
it is at least much exaggerated ; for the people who occupy the
regions of the extreme north, as we say, have the most beautiful
teeth. It is not, then, very probable that cold by itself exerts an
unfavorable influence, but only the sudden passage from a warm
temperature to a great cold, which, destroying the equilibrium
in the cohesion of the molecules which compose the teeth,
causes in them hasty movements of dilation and obstruction, the
more common result of which is caries.
As to the preference which caries has for the two superior inci-
sors instead of the lower ones, all things besides being equal, it is
explained, according to our opinion, very naturally, by the posi-
tion of the first, which renders them more exposed to the action
of external bodies. Finally, in the action of prehension of liquids,
or, to speak plainer, in the action of drinking, they receive
nearly always the impression of the fluids, which the inferior
are prevented from, even by the vessels we use.
A great number of bodies cause caries by their chemical ac-
tion. It is thus that acids act, although it may not be as easy
PATHOLOGY AND THERAPEUTICS. 159
as it might be thought to explain why this chemical action en-
genders caries sooner than a simple decomposition of enamel ;
which, according to our opinion, is another thing.
An able dentist of our day, Regnard,* it is true, considers ca-
ries only as "« destruction of the teeth by decomposition ^^^ and
this decomposition finds only a cause in an acid developing it-
self, either in the humors of the mouth, or in the alimentary
substances which remain around the teeth. "He gives as a sup-
port to this assertion three proofs, thus :
"1st. Artificial teeth were fastened by threads of silk. These
threads, which surrounded the neighboring teeth, became im-
pregnated with saliva, and covered with alimentary particles, and
soon corrupted them ; they became then a cause of caries to the
teeth. This is so true, that the limits of the caries proceeding
from this cause are traced by the thread itself.
"2d. For sustaining the artificial teeth, metallic caps were
made to envelope one or more of the teeth. These constantly
served to remove the pain produced by the rapid wearing away
of the teeth. These caps were not made with so much preci-
sion, that there did not exist any space between them. The
fluids of the mouth, the alimentary particles, soon lodged in
these spaces ; and if persons who wore these caps were not very
careful, these fluids of the mouth, these alimentary particles, de-
composed, and became then an active cause of caries to the
teeth. I have seen molars whose crowns were entirely destroy-
ed by the action of this cause in the space of six, five and even
four months.
"3d. Human teeth and the teeth of the hippopotamus were
used for artificial teeth. These teeth being of an organic nature
are capable of decomposing in the mouth. Then, if by a badly
arranged economy, the persons who wore them preserved them
still when they are in a state of decomposition, they decayed the
neighboring teeth, which are immediately in contact with
them."
Regnard strengthens these different proofs by the following
considerations :
^^iiy now, I devote my attention to the parts of the teeth in
» Of Dental Caries. Brochure m 8, Paris, 1838.
160 ANATOMY, ORTHOPEDIA,
which decay commences, I see that they are precisely those
where the aUments and fluids of the mouth stop and remain
sufficiently long to decompose themselves. It is in the necks
of the teeth, in the interstices of these organs, in the anfractu-
osities of the large molars, in these pointed holes, that we ob-
serve sometimes upon the external face of the first and second
large inferior molars or upon atrophoid teeth. If we reflect pre-
cisely upon the mode of action of caries, we see that they act in
the same manner as an acid, that they deprive the tooth of its
phosphate of lime, and upon the point where it exerts itself it
reduces it to a cartilaginous substance. Let us see if we can find,
in the decomposition of the alimentary particles, or buccal hu-
mors, an explanation of this phenomena. Now, chemistry
teaches us that all vegetable or animal substances, in a state of
decomposition, give birth to acidiferous products ; to nitric acid,
acetic acid, sulphuric acid, etc. all acids which produce the
same effect as caries upon the teeth."
To take the action of acids upon the teeth as cause of decay,
in as absolute a sense as Regnard, is, according to our opinion,
an error, a great error. In adopting it, to the exclusion of all
other causes, this practitioner commits the same fault that a sur-
geon did who, in order to demonstrate that a fall upon the wrist
would disjoint the arm, would minutely describe how it acted in
the production of luxation, and who, for the correlativeness ex-
isting between the cause and effect, would conclude that the
arm did not disjoint only in a fall upon the hand.
If we were not prevented by the fear of being too extended
upon a pathological point which, all important as it is, is not
however the only thing to study, we might make innumerable
objections to the theory of Regnard ; but we will confine our-
selves to the five following, that we shall expose in the order of
their importance :
1st. A great number of caries commence in the ivory which
is often deeply affected whilst the enamel is entire ; a circum-
stance which has entirely escaped the notice of Doctor Serrurier,
who, however, has made a very judicious refutation of the trea-
tise of Regnard.*
* See the Gazette of the Hospitals of the 20th and 25th of September, and
\Uh of December, 1838.
PATHOLOGY AND THERAPEUTICS. 161
2d. Many teeth, principally the last large molars, come from
their alveoli deeply decayed, without having consequently been
submitted to the action of any kind of acid.
3d. If it was always and solely an acid which affected the
teeth, this action would be general; it would not have but one
point of decay ; the whole of the dental system would be certain-
ly decayed.
4th. It is against the evidence of facts that Regnard declares
that the use of cider, among persons who inhabit Normandy and
Picardy, accounts for the frequency of caries ; for, Rosseau re-
marks justly, that the inhabitants of these two provinces who oc-
cupy healthy places, "have most generally the most beautiful
and healthy teeth,"* contrary to that which befals those who oc-
cupy low places, that is to say humid ones.
5th. Finally the saliva and buccal humors are not as frequent-
ly acid as Regnard thought ; we have often found alkalies
among many persons who had their teeth deeply decayed. Our
researches, in this respect, accord perfectly with the opinion of
Doctor Donni, who expresses himself thus :
f'The alkalinity of the saliva has been avowed long since ; but
it has been proven only in these latter years, particularly by the
experiments of Tiedman and Gmelin."
Donni is not satisfied even with proving the alkalinity of the
saliva, he endeavors also to explain it in these terms ; ancient
and modern authors have said nothing of the part that relates to
the alkaline principle of the saliva. Beyond the usages that is
generally attributed to it, it seems, according to my researches,
to neutralize the excess of the acid of the gastric juice. This is
supported, by most experimenters ; 1st, upon the neutral state of
the gastric fluid ; 2d, upon the impossibility that this effect can-
not produce the salts and saliva found in contact with the acid
of the gastric fluid ; 3d, upon the nature of the salts, contained
in the gastric fluid, a great part of whose basis is salts."
Whatever may be the opinion of Regnard, we do not at least
acknowledge that the presence of the acidity of the saliva, upon
a point of the enamelled substance, might be a cause of decay;
■* Work quoted, page 225. f Work quoted.
21
162 ANATOMY, ORTHOPEDIA,
but then we admit that the person is under the influence of
some derangement of the digestive organs, as the author that
we have precedingly named estabhshes so clearly in this re-
mark : "This acidity of the saliva coincides the most frequently
with a primitive or secondary state of irritation or inflammation of
the stomach, and can serve to establish the differential diagno-
sis of some gastric affections, " To prove this acidity it is only
necessary to place upon the tongue a piece ofblue turnsole paper :
if the paper becomes red, we can predict that the subject is un-
der the influence of some disease. We have also remarked that
this acidity coincides often with a thready, thick or glutinous
state of the saliva.
The use of certain medicaments, as of mercury, gold, mineral
waters, acting equally upon the teeth of their chemical proper-
ties, can also be, not only the predisposing, but direct cause of
caries. Blows, falls, commotions, and counter blows cause vi-
cious conformation and too great nearness of the teeth, &c.
We might add to this series, a crowd of other causes that au-
thors have mentioned, but they would be too long and super-
fluous to enumerate here. And how could we explain, in this
multiplication of causes of decay, the diversity of effects which
produce this kind of dissolution of the teeth, and the variety of
aspects under which it presents itself when we consider it, either
under the relation of the color and form of the spot which an-
nounces its existence, or under that of the place that it occupies
or, finally under that of the rapidity or slowness with which it
proceeds in its course?
2d. Symptoms and Course. — Caries, according to our know-
ledge, as we have already said, proceeds frequently from the in-
terior to the exterior. Smote in its vitality, either by an act of
nature that cannot be explained, and to which the pulp is not
always a stranger, or because the delicateness of its tissue was
not able to resist the agents with which the teeth are constantly
brought in contact, the ivory becomes the seat of a change
which aflfects at the same time its color and the force of cohe-
sion which unites its particles. A yellow or brown spot mani-
fests itself near the enamel, which it invades by degrees until it
extends upon the surface of the crown. This envelope loses in
PATHOLOGY AND THERAPEUTICS. 163
this respect its transparence, a natural consequence of the sepa-
ration of the elements which constitute it. Whilst the internal
layer of ivory which unites the enamel with the sifhjacent lay-
ers is not destroyed, the spot preserves the color and even shin-
ing aspect which belongs to the teeth ; but it loses this brillian:
cy as soon as the connection is severed which binds the ivory
and enamel together.
As there are a great number of external agents which have
the power of destroying the cohesion of the elements of the ena-
mel in its most superficial layers, without effecting its deepest
layers, often the tooth loses its transparence upon the point at-
tacked, without losing any of its whiteness. The evil does not
extend ; the decay is arrested there ; often it gives no other sign
of its existence than a slight depression resulting from the dis-
engregating of the elements of this envelope, an effect which
mastication produces sooner or later; it is this that authors have
called dry or stationary decay. It is rare, however, that this de-
pression is not succeeded by a yellow spot; for nearly always
the salivary fluids deposit a sediment there which alters the
color of its subjacent layer. Besides the contact of the air suf-
fices to change the whiteness of the crown deprived of its enamel.
Gradually the tissue of the tooth softens in the place where
the yellow spot manifests itself. It forms there a cavity which,
increasing in consequence of the progress of its destruction, re-
duces the enamel to the most superficial of its external layers,
so that this substance, being deprived of support, breaks and dis-
closes decay. This cavity thus formed, increases gradually in
the interior, representing a cone whose base is at the surface,
and whose diameter diminishes in proportion as its depth dimin-
ishes.
The course of this first period of the decay is ordinarily slow,
and often the person who is affected is warned only by vague
sensations, by obscure pains and the bluish tint of the tooth,
which, to a practised eye, is a certain sign of the existence of
decay. The opening once formed in the enamel, continues gra-
dually to enlarge. If, however, it does not increase, it is be-
cause the force of the destructive agent has ceased to act upon
the opening, and is confined entirely to the internal layers of the
164 ANATOMY, ORTHOPEDIA,
ivory. It forms there, with the assistance of atmospheric air
and other destructive agents, a large and deep cavern which
presents exteriorly but a small opening ; the enamel may be
easily broken, and we discover as in another case, the extent of
the ravages in the interior of the tooth. Authors have called
this humid caries.
The progress of decay is, in general, more rapid among young
subjects and among lymphatic individuals; pregnancy appears
also to have a great influence upon its course. But it is princi-
pally afterwards that it appears externally, that its progress is sen-
sible, as we will now show. Its cavity is entirely filled with a
soft, brown, yellow or black matter, of a fetid odor, that the in-
strument can easily divide and detach in successive layers,
which become denser as the healthy parts are approached. Tfiis
matter, which, according to Regnard, acts as an acid, assists
powerfully by itself to extend the evil ; it constitutes one of the
most active causes for propagating the decay.
When the caries has penetrated to the interior of the dental
cavity, the pulp finds itself in contact with external influences
and becomes sensible to heat and cold and the impressions of
hard bodies. The tooth is then the seat of obstinate pains
which sometimes are spontaneously disclosed, sometimes pro-
voked by the slightest exterior causes. These pains manifest
themselves generally by access, and are accompanied by all the
symptoms of a local congestion, and to which is added many
times different nervous complaints. Throbbings are felt in
the tooth and often in the temporal arteries, and an abun-
dant salivation afterwards follows. This paroxysm, which
is more or less long, is repeated at different intervals, and are
often only the prelude of inflammation and suppuration of the
pulp ; fi-om thence is produced more or less serious inflamma-
tory fluxions and different disorders.
If, in this state, one removes the tooth, its cavity is found fill-
ed with a greenish and very fetid matter. Its vessels trace
across the ivory of the root a black color ; the dental cord is very
large and filled with blood. Thus deprived of the organ of its
vitality, the ivory continues to be destroyed ; the enamel alone
remains, becoming broken off" by fragments, and finally the root
patholoCtY and therapeutics. 165
alone remains, which ceases generally to be painful nntil extrac-
tion, displaying itself in being extracted. All these ravages
have place in the interior of the tooth, without they are called
by some other symptom, but we do not observe their exist-
ence before the rupture of the layer of the enamel, if, as the
principle of evil, it is not accompanied by a pain at first obtuse
and like a dullness, but finally becomes very acute. Caries of
this kind, although less common, are nevertheless met with
very often.
Caries presents, in its course and in its symptoms, a number
of modifications, which it will be difficult to describe; which,
however, some authors have attempted to reduce to species.
Among others, Uuval admits seven, that he calls calcareous^
decorticating^ perforated^ carbonated^ disruptive^ stationary and
erosive decay. Maury has punctually followed this division.
We do not follow it for two reasons : the first is, the characters
which serve as a base for them are very variable, and altogether
arbitrary, and that many do not really belong to caries, but to
defects altogether difierent, with which Duval has confused
them. The second motive is, that in multiplying divisions and
subdivisions, in the study of specialities, it seems as if we wish
to withdraw from the organs upon which they exercise the
general laws of common life, which, ordinarily, ought to suffice
to explain all. The adoption of the division of Duval causes us
to regard caries as the type of all the diseases of the teeth, and
of their changes that we have already described, under the names
oi discoloration and decomposition, and of erosion, and which we
shall soon examine under those of the loearing aioay and even
oi fracture. This will approach least to error.
If it is necessary to adopt a division, to facilitate the study of
the disease which we are now treating of, we do not hesitate to
receive that which we have formerly proposed, according to
which there are two fundamental distinctions, under the names
of dry or stationary caries and humid or progressive. If it limits
too much the shades of caries, it has at least this advantage, that,
in a practical point of view, it unites the most important charac-
ters of the disease, that which, consequently, renders it more
just, and better founded than the most of the numerous distinc-
166 ANATOMY, OR'l HOPP:DfA,
tions that the desire of novelty and singularity has sought, in
our day, to establish.
3d. Seat. — It can be said, in general, that there is no totnh
the seat of decay, for all are subject to it ; some, however, more
so than others ; the molars are principally aflected. The inci-
sors and canines of the upper jaw are more frequently affected
with it than those of the lower jaw ; it shows itself nearly always
upon the sides of the anterior teeth ; less frequently upon
their external face ; more rarely still upon their lingual or inter-
nal face, and scarcely ever upon their cutting edge.
The large molars are frequently decayed upon their sides
which touch each other, but more commonly it appears in the
midst of the depressions of their triturating faces. If the teeth
of this class are more subject to decay, it is because they pre-
sent the most extended surface, and because the layer of enamel
which covers their trituratiug surface is often weak and badly
crystallized between the tubercles and sinuosities of the crown.
It is necessary to add to these reasons the power of the mechani-
cal forces which have the greatest resistance to overcome in the
act of mastication, and the particles of food which remain in
their depressions. The lateral sides of the small molars are at
least as subject to decay as their triturating borders. Those of
the lower jaw, but one point clearly marked, the same is thecase
with the incisors and canines.
Finally, the teeth do not always commence to decay upon
one point. We often find caries between all the eminences of
the molars, upon the two sides of the anterior teeth, and some-
times even upon different parts of the same side. All the parts
above the gum, being more exposed to the action of exterior
causes, can consequently be affected by it.
The first signs of decay manifest themselves sometimes at the
place where the enamel terminates, that is to say, the neck of
the tooth ; but its progress is generally terminated here, and
leaves the root untouched. There are, nevertheless, examples
of the root being affected ; it is, however, very rare that the dis-
ease penetrates to their extremity; they are changed only in
some parts of their extent ; still it is necessary to avoid consider-
ing the different affections of the root as belonging to caries, for
PATHOLOGY AND THERAPEUTICS. 167
very often, as we have already said, they are the results of
morbid effects of the periosteum, which cause disorders more or
less serious.
There is no practitioner who has not remarked that the cor-
responding teeth in the same jaw are very often attacked with
caries at the same time, or at very near intervals. This co-rela-
tiveness is so evident to every one, that authors have sought to
explain it. Some confine themselves merely to saying, that the
corresponding teeth in the same jaw, being of an identical
texture, become decayed at the same time ; others, that the dis-
tribution of nerves being the same in them, they necessarily are
equally susceptible, and yield at the same time to the active
causes capable of producing unfavorable effects upon the dental
system.
Neither the one or the other of these two explanations, given
for the purpose of contenting superficial minds, are admissible.
In effect, the texture of all the teeth, except in regard to their
quantity of matter, being identical, nothing, in this respect, can
explain why the corresponding teeth in the same jaw are de-
cayed at the same time. The distribution of the nerves can
explain this phenomenon, if each dental nerve comes directly
from the sensitive system to the tooth that it is required to give
life to ; but, as we know, each of these diverse fibres comes
from a common trunk, which communicates to all an identical
sensibility, we can deduce nothing from this.
The following, according to our opinion, is the only explana-
tion which seems rational : the teeth which correspond in each
jaw, being generally submitted to the same phenomena of forma-
tion, development and appearance, ought, then, to possess an
equal degree of vitality and sensibility, and consequently are
compelled to yield at the same time to the action of agents
which might put in play the predisposing diseases with which
they are affected. This opinion confirms, besides, two asser-
tions that we have already put forth and developed ; to wit,
that a great number of the diseases of the teeth date their forma-
tion from the follicles, and that caries is very often the result of
interior causes.
Finally, the wisdom teeth are sometime decayed when they
168 ANATOMY, ORTHOPEDIA,
are cut, especially when their eruption is retarded ; this fact will
also assist to prove that which we formerly endeavored to do,
namely, that the acids that the aliments contain, or which form
accidentally in the mouth, are not the principal causes of caries.
The milk teeth are very often affected, generally the molars,
and particularly the inferiors, whose roots destroy themselves
gradually, even to the crown. These are often forced to be ex-
tracted without the teeth of replacement, which are ordinarily
separated from them by a partition, undergoing any change.
But that which is still more remarkable, and which, to our
great astonishment, we do not find described in any work, is,
that the caries of the milk teeth cause very rarely those sharp
pains which accompany so frequently that of second dentition.
For do we not see small children carried to a dentist, on ac-
count of true dental pain? When we reflect, we see that it
might necessarily be thus, because these teeth, condemned to
fall, are separated, at an early period, from the centres in the
midst of which they derive the materials necessary to their life
and sensibility. The practical consequence which flows from
this fact is this, when a child is brought to us for the purpose of
preventing pain coming from the milk teeth, instead of treating
the decay, we should examine if some fragments of roots do not
tumefy the gums, or even perforate the alveoli, &c.; and we will
be assured that that pain is produced by some tooth ready to
be cut, or by another cause.
4th. Diagnostic. — It is not always easy to discover caries,
when it has not manifestpd itself by any external sign. The
sensibility and pain, which often causes us to suspect them, do
not always exist ; we have even seen persons lose a part or all
of their teeth, without experiencing the least pain. Sometimes
caries manifests itself by sympathetic pains, as chronic opthal-
mies, otites, stubborn coryzas, etc., which cease, as by enchant-
ment, after the extraction of certain diseased teeth.
Then the pain and sensibility experienced by heat and cold,
and by the contact of hard bodies, are not certain signs of
caries, since they could be completely in fault. The inspection
of the teeth remains to prove it, which, in general conducts to
a more certain diagnostic ; we say, in general, for in some cases
PATHOLOGY AND THERAPEUTICS. 169
we are obliged to resort to another mode of examination, which
consists in percurating, successively, the teeth, one after another,
by means of some hard body, until, by the pain or sensibility,
we can determine the right one.
5th. Prognosis. — The prognosis of caries varies according to
the extent, the seat, the progress and nature of the affection, and
often according to the constitution, the age of the subject, and
the diseases to which he has been exposed. Decay which
attacks lymphatic individuals, whose parents had lost their teeth
in early years, those which attack at the same time a great
number of teeth, are in general a sad omen; for they are always
followed by a total destruction of the dental system. That
which is of a yellow color, ordinarily progresses more rapidly
than that which is black. When its seat is at the neck, it is
always more dangerous, because the destruction is very near
the dental cavity, and necessarily reaches the pulp sooner.
Again, this kind of caries is sometimes concealed, and we are
not consulted in relation to it, until it has made great progress.
Finally, experience attests that caries which affects persons
who have a compact denture is always more dangerous. If we
wish to enlarge this volume, and to deprive it of the practical
character that we had intended giving to it, we might seek why
the too great nearness of the teeth is harmful, and becomes, in a
great number of cases, a cause of caries and a means of increasing
the disease. But it suffices us here to prove the fact, and to re-
mark that a modern author* has perceived himself able to explain
it, in saying that caries proceeding from the obstacle that the near-
ness of the teeth offered to the free course of the fluids which
circulate in the enamel ; but this is a hypothesis too gratuitous,
and which has not the appearance of reasonableness. By what
means, then, can we remedy the inconveniences of a too com-
pact denture ? By separating, with a file, the edges which
touch. Now, a loss of substance might oppose still more the
free course of the fluids of the enamel. We will return again to
this subject.
6th. Treatment. — If, from pathological considerations which
* Delabarre : work quoted.
22
170 .^NATOMY, ORTHOPEDIA,
precede, we pass to the therapeutical question, we must acknow-
ledge that, in the treatment of caries, we ought to have in view
but three distinct objects: to preserve the teeth healthy and
from all disease ; to seek to remedy their disorders by endeav-
oring to arrest their progress; to destroy or alleviate their
pains.
To accomplish the first, we must remove all the causes, that,
directly or indirectly, cause or develope caries ; and we can ar-
rive at this result only by following, with punctuality and per-
severance, the hygienic precaution and cleanly habits, to the
development and explanation of which we have devoted a chap-
ter. If the tooth is badly decayed, it is necessary to extract it,
or if it is possible to plug it, or if the disease is light, to isolate
the affected part by the use of the file ; for it is an incontestable
fact, that caries can be propagated by simple contact, whatever
may be the explanation of the means we have sought to give of
this propagation.
The natural deduction, from what we have previously said, is
to separate, at an early period, the decayed teeth that touch, and
for a still stronger reason those which thus change rest one upon
the other, generally, when this vicious disposition is carried too
far, others multiply. Many practitioners, struck, without doubt,
with the insufficiency of the explanation given of the propaga-
tion of caries from one tooth to another, have_ denied the utility
of this operation, because some persons have preserved their
teeth free from decay, notwithstanding their close proximity.
This reason is specious, for it rests upon exceptions, which
proves nothing in the presence of the plurality of cases which
attest this law of communication.
Let us, then, conclude, that when the decay has made but
little progress, and affects their lateral surfaces, it is necessary
to hasten to remove, by means of the file the decayed portion.
But when it has been carried so far that it occupies the external
or internal side of the crown, when it will be difficult to use the
file, it is necessary to plug the tooth, or, to speak more concisely,
to fill it with leaves of gold, silver or platina, or some other sub-
stance capable of exactly filling the cavity, in such a manner
as to completely exclude all foreign substances.
PATHOLOGY AND THERAPEUTICS. 171
This operation succeeds in a greatnumberof cases, especially
if the dental pulp has not been exposed. But if it has been, it
is necessary to proceed with prudence to those operations, the
results of which might be injurious ; for it is easy to perceive
that if the tooth be the seat of a sharp pain or acute inflamma-
tion, the presence of foreign bodies employed to fill the diseased
cavity, would only augment the one and favor the other. Some
practitioners abstain from plugging teeth in pregnant women,
under the pretext that they have seen accidents follow the most
simple operations, especially among women who have a dispo-
sition to dental fluxions ; they prefer, when pregnancy is much
advanced, to wait until after the birth of the child. We do not
approve of this plan ; for, during pregnancy, the caries lias at
the same time destroyed the tooth altogether, and causes us to
regret a temporization that, according to us, notliing will justify.
According to our opinion, even in the exceptionable condi-
tions that we have mentioned, it is necessary to remove the
caries promptly from the action of the air, and the contact of ali-
mentary particles ; for among these persons it progresses with
fearful rapidity, and communicates easily ; to temporize it would
be an imprudence which has the double inconvenience of favor-
ing the progress of the decay, and of rendering it difiicult or
impossible to keep the mouth clean.
Some dentists, struck with the inconveniences of plugging
teeth affected with humid caries, have proposed diff'erent sub-
stances to dry these caries, and to render the tooth in a fit state
for natural remedies, by the hardness that these substances have
appeared susceptible of acquiring. These pastes are composed
of different salts and of some sharp narcotic powders, to which
they have given the name of obliteric cement, or something
analogous to it. As these pastes, notwithstanding the hardness
that they can acquire, do not dispense with plugging, we believe
them to have been advised rather by the desire of attracting
public attention, eager for novelty, than by the wish to disclose
a therapeutical indication rationally established. We will speak
more of it in future.
Dental caries, we have said, is ordinarily accompanied by
pain, which constitutes a particular indication for treating this
172 ANATOMY, ORTHOPEDU,
disease. When these pains have acquired an extreme intensity,
and have become permanent, without doubt the tooth should be
extracted, which is the seat of the disease, as this will relieve the
pain. But, in many cases, the pain is slight, and manifests itself
at distant intervals, and only as the result of accidental circum-
stances, whence it is easy to recognize the cause, and to destroy
or moderate the effects. It would then, at least, be imprudent to
sacrifice an organ scarcely affected, which might in a moment
have its pain removed, and still render important services.
As decay is the cause of the extraction of a great number of
teeth, perhaps it is this more than any thing else which in-
duces us to blame the readiness with which a number of per-
sons, for a slight pain, wish a tooth extracted, and the cold in-
difference with which certain dentists accept their proposition.
Let any one reflect an instant, either upon the mutual relation
which exists between the teeth and the bony cavities which re-
ceive them, or the reciprocal support that they furnish one
another, and he will be fully convinced that their great solidity
depends in part upon the preservation of them all.
In extracting a tooth, we shall see, in the description of
operative mechanism, what precautions one should take in per-
forming this operation, for he is liable to fracture more or less
the bony partition which forms the cavity destined to receive it.
This fracture causes a weak point in the maxillary arch ; the
necessary consequence is then, by the collision of the jaws
in the act of mastication, that all the teeth, pressing towards
this point where it finds a defective resistance, are liable to lose
that firmness which they enjoy in their natural state. Without
doubt we see every day persons who have very solid teeth,
although one or more teeth may be wanting; but these excep-
tions do not destroy the physiological reason by which we could
prove that the teeth themselves furnish reciprocal aid.
Being convinced of this fact, the dentist ought then, in nu-
merous instances, to seek to calm the pain before resorting to
the extremity of extracting. And certainly, if the possibility of
arriving at this result be proportioned to the multiplicity of the
means proposed to this eflfect, the destruction of the pain will be
the simplest and easiest thing in the Avorld ; for there is no point
PATHOLOGY AND THERAPEUTICS.
173
in medicine, however fruitful, upon which the genius of thera-
peutics, might not be exercised. Many persons, guided unfor-
tunately more by the desire of gain than by the love of science
and good of mankind, make sport of deceiving the credulity of
the public and their taste for the marvellous, by giving, as certain
specifics, either efficacious means, but which, reduced to their
just worth, have but a circumstantial action, or other means ab-
solutely useless, but whose imaginary action, depends upon cer-
tain imposing or mysterious demonstrations which accompanies
their employ.
Truly, as a modern author remarks, these are the fallacious
promises which have sharpened against us the arms of the sa-
tirist, whose darts are not only too just in numerous instances,
but which prejudice many persons unfavorably with regard
to our art, thereby preventing them from counselling us, which,
had they have done in time, might have preserved their teeth
but slightly altered, and prevented them from sustaining so
many painful operations to which improvidence reduces but too
often to our calling.
"It is in vain that experience has proven a thousand times the
inefficacy of most of the sovereign remedies to cure the pain
dental caries occasion, still they are sought with eagerness, and
received with an admiration which, without legitimacy, shows
perfectly at least the net drawn on all sides for the credulous
public. Happily the vogue of this remedy is as ephemeral as it
is great ; but so great is the fear of pain, that persons are mis-
taken, and a number belonging to the enlightened classes of so-
ciety have recourse to their use. These remedies, which have
appeared with so much brilliancy at different epochs, have fin-
ished their career by being unmasked."
To the eyes of every enlightened person, the means employ-
ed for calming pain, caused by caries, ought to differ as much as
this disease varies in its intensity, its cause and its nature.
Whatever may be these means, their mode of action is reduced ;
first, to calm the inflammation of which the dental pulp or the
auxiliaries of the decayed tooth might be momentarily the seat ;
secondly, to excite another part more or less distant from the
diseased tooth, and to absorb thus the pain in this last ; thirdly,
174 ANATOMY. ORTriOPKUTA,
to suppress locally or generally or even to destroy the sensibili-
ty of the tooth ; fourthly, to withdraw the cavity of the caries
from the action of the air, of alimentary particles and from all
matter more or less irritating, with which it may come, in con-
tact. There is no substance having any efficacy, whatever may
be the prestige or secret of its use, even emuletes on and reme-
dies of commerce, which does not belong to one of the four classes
of which we shall now speak. We will pass them successively
in review, and reduce them all to their just worth.
The means which belong to the first are the antiphlogistic.
These are employed, although their name indicates this, when
the pain is developed with inflammatory characters, as for ex-
ample, when it appears under the influence of a sudden change
of temperature ; when the gum surrounding the decayed tooth
is rough and tumefied ; when the neighboring parts, which
seem to occupy all the side of the jaw from the diseased tooth,
are swollen, and when the vital reaction is made known by an
elevation of the pulse, a redness of the face and a beating of the
temporal arteries.
The most efficacious of these means are sanguine evacua-
tions, general or local. The first is obtained by opening a vein
in the arm or foot ; the second, by applying some leeches behind
the ears or below the angle of the jaw, and even upon the tume-
fied gums. This last means, although it remedies the disease,
is more simple and less difficult to employ than is commonly
believed ; it consists in enclosing a leech in a glass tube, and
presenting its buccal extremity to the gum that it may deprive
it of its superfluous blood ; this can be accomplished still better
by scarifying it first with a small lancet. These sanguine evac-
uations are commonly followed by diet, drinks, softening gar-
gles, fumigations, cataplasms, and applying upon the gum a
warm fig, etc.
In the second class are arranged, under the name of deriva-
tives or revulsives, all the means capable of producing reactions,
pediluvia and sinapisms, applications of cold water to the head
and upper part of the neck, and of blisters and cups behind the
ear.
Finally, sudden moral feelings, strong impressions, which
PATHOLOGY AND THERAPEUTICS. 175
sometimes instantly calm the most acute dental pains, among
nervous persons, are only derivatives which, affecting the brain
immediately, convey the painful sensation from the cavity of
the tooth. We can then attribute to fear the cessation of pain
which so often takes place, as by enchantment, even when the
patient arrives at the door of the dentist, or, in other cases, at
the sight alone of the instruments which are employed in the
extraction of a tooth. Sometimes an energetical purgative has
produced the same result.
In the third class are placed the innumerable odontalgics^ or
means which are employed for the purpose of calming or even
of immediately destroying dental pain. They act in three
ways : narcotics, which moderate active sensibility; they com-
prise all preparations in which opium, camphor, henbane and
belladonna enter ; tinctures and natural oils, which excite the
the membrane which lines the dental cavity ; finally, concen-
trating acids and .cauteries, which cauterize either the dental
nerve, or the decayed part.
Opium is ordinarily employed in the state of an extract, and
in doses of one half a grain, which is dropped upon cotton, and
then placed in the cavity of the tooth ; the tinctures are fre-
quently of myrrh and spoon wort; and the essential oils those of
mint, cloves, cinnamon and cajeput ; we might add a number
of other preparations, as, for example, a plant known under the
vulgar name of catsherb, {nepeta cataria de Linne,) whose use
Dr. Guastamacchia recommends, and which have nearly the
same chance of success. Their mode of employment is similar
to that of the acids, with this difference, the moist cotton should
be covered with a piece that is dry, in order to preserve the
neighboring parts from the irritating action of these substances
which is either hydro-chlorig acid or tincture of cantharides and
creosote, &c.
With regard to the actual cautery, it is the most certain means
that can be used ; it joins to the promptness of its action an
almost uniformly happy result. This operation, advised by
Ambrose Pare, limits the extent of the decay, by disorgan-
izing the vascular nervous pulp, and reducing it to an inert
state. It is to be regretted that this treatment has some incon-
176 ANATOMY, ORTHOPKDIA,
veniences, which often counterbalance the instantaneousness of
its action : thus, for example, if we wish to preserve a part of
the decayed tooth, it is sometimes injurious, because, in remov-
ing the cautery from the crown of the tooth, the caloric will, in
certain cases, crack the enamel, and render the bad effects still
greater ; finally, it is not very easy to limit this action ; inflam-
mation follows, which extends to neighboring parts, and gives
rise to fluxions and abscesses in the alveolus.
From this physiological mode of the action of the various
agents admitted, or made known by charlatans for allaying pain
arising from caries or other affections, the result evidently is, that
there is no true specific for the relief of this pain. Thus, some
practitioners, wishing to find a remedy that would be apphca-
ble to most cases, have proposed preparations which consist
of the union of substances the efficacy of which was least
doubtful. It was this idea which induced Dr. Handel, of Metz,
to prepare the following preparation, whose action might be
very advantageous :
R Opium, 5 ss,
01. henbane, . . . . 3 i>
Ex. belladonna, . . . • gr. 10,
Camphor, gr. 10,
01. cajeput, . . . . • § ij
Tr. cantharidei, • . . . § i. Misce.
This opiate and similar ones seem convenient, as Maury
with reason remarks, when the odontalgy caused by the caries
has its seat in the superior jaw, because we can apply them
in an immediate manner ; which might not be as easy if we
employed medicinal liquids. We can make for the same pur-
pose a paste consisting of a concentrated decoction of roots of
sweet fennel, ginger, frankincense, heads of cloves and of cin-
namon, reduced to the necessary consistence. We notice that
this means has in view an irritation sufficiently great to inflame
the dental pulp, and under this influence it ceases to be
sensitive, by the destruction of its vitality.
Finally, in order to complete the list of means prescribed to
arrest caries, or the evils attendant upon them, we should men-
tion camphor, which a learned chemist has recently prescribed
PATHOLOGY AND TlltRAPEUTlCS.
177
as an infallible remedy.* The therapeutical indications upon
which this is founded, is the destruction of the worm which, ac-
cording to some, accompanies the disease. This opinion is not
new, as we perceive •, for it is the basis of all the boastings of the
charlatans, who seek to deceive the blind credulity of the people.
We should, then, refuse to give credence to this, although, by
means of microscopic examinations, made without prejudice,
we have sought to enlighten ourselves ; and we see, in the cam-
phor, only a substance which adds to its anti-spasmodic quali-
ties the odontalgic action which it exercises sometimes.
Concerning all of these means, and an infinite number of
others, which ignorance and cupidity daily divulge to the marvel-
lous, if they succeed sometitues, they fail oftener, and frequently
the patient is relieved of his sufferings only by fluxions, which
cause the suppuration and destruction of the dental pulp.
When the caries has made extensive progress, the extraction of
the tooth can only free the patient from the lacerating pains that
habitually accompanies it. Before adopting this final operation,
many authors have proposed other means.
One of the most specious is the excision and extraction of
the dental ganglion ; for this operation a small drill is used,
which is placed in the cavity of the fang, and, giving the drill
a few rotary motions, it is withdrawn with the dental pulp
attached.
Delmond has described, with care and much detail, this ope-
ration.! If we have not at hand the proper instrument for this
operation, a substitute might be made of iron or platina wire,
resembling a single /acies, and which can be readily introduced
into the canal of the tooth. By giving the wire a shape resem-
bling a cork-screw, we can with it readily withdraw the dental
pulp.
When this method, which cannot be employed excepting for
the six anterior teeth, on account of a number of difficulties
which we might mention, and when the crown is not suffi-
* M. Raspail, Letters on the Medical Virtues of Camphor, in the Hospi-
tal Gazette, November and December numbers, 1838.
t A Treatise upon a New Method of Destroying the Dental Pulp. Paris,
1824.
23
178 ANATOMY, ORTHOPEDIA,
ciently injured for us to decide to sacrifice the tooth, some prac-
titioners prefer to trepan it in the direction of the root, with a
small burr drill. The dental cavity being thus exposed, they
destroy the nerve, and plug it, after having kept it filled with
cotton several days, if the cavity continues healthy. In
speaking of Oudet, as a practitioner who frequently adopts this
method, we do not pretend to say that he was the originator of
it; for we find, in the Medical Review, 2i detailed description,
given by Fattori. "This method," say the compilers of the
article, "is entirely based upon this principle, that, whatever
may be the cause of the pain, it ceases when we extract the
nerve, or in any other way destroy it. It is necessary, then, in
order to remove the pain, to find a mode by which we can cut
ofi" the dental nerve at the point where it enters the tooth. It
is this to which Fattori has arrived. By means of suitable
needles, which he adapts to a trepan, he cuts off the nerve, after
having promptly perforated the painful tooth, which becomes,
by this operation, ever after insensible."
This operation, unfortunately, is as far from being certain in
its results, as it is ingenious and rational. From the knowledge
which we have of the anatomy of the teeth, is it always certain
that we can strike the nerve in perforating the tooth ; and if, as
It might ordinarily happen, the operation has to be repeated,
what one will be sufficiently patient to endure the pain of a
second operation, and honest enough to avow that it is not
equal to the loss of the organ? This operation, to say the least
of it, is rarely successful ; and not much can be gained in per-
forming it upon teeth which have but one root.
M. Malgaigne thinks that, in executing the operation of Fat-
tori, it is necessary, at least for the posterior teeth, to make a
large incision in the gum, and finds that some advantage is ob-
tained by extracthig the tootli posterior to the origin of the pain ^
in order to permit the proper instrument to be introduced to di-
vide or crush the nerve, to the depth of its alveolus. We will
first remark, that if Fattori had ever dreamed of making an inci-
sion in the gum, for facilitating the operation he recommends,
the remedy truly is worse than the disease. We remark, sec-
ondly, that, since Malgaigne recommends the extraction of a
PATHOLOGY AND THERAPEUTICS. 179
tooth, it would be better to extract that which is diseased ; there
are one hundred probabihties to one, that the pain of the opera-
tion would be greater than the patient could endure. The
manner in which the nerves of the dental apparel are distributed
strengthens this belief; it is certain that the destruction of the
nerve of one tooth, a nerve which has nothing in common with
the one preceding it, is a means incapable of destroying the one
which adjoins it, much less could the destructive instrument
reach the common trunk of the nerve, that which would be of
great inconvenience, excepting in cases of very intense general
dental neuralgias, as we shall soon see, in speaking of nervous
diseases of the teeth.
Ambrose Pare and Urbain Hemard have also advised, in
case of caries, to excise the crown of the tooth. They call this
operation decapitation of the tooth, doubtless in opposition to
the chaplet that the teeth form over the nerve, by the union of
their bony structure ; this operation is followed by cauterization
of the nerve. But it is not always exempt from danger; the
shock communicated to organs which are already the seat of an
exquisite sensibility, and other accidents that often follow it,
have caused it to be neglected by modern practitioners. We
perform it constantly only for the six anterior teeth, when we
wish to preserve the roots, in order to adapt artificial crowns to
them. In order to practice this excision, which is generally
very painful, we should, as we shall see hereafter, grasp the
crown with excising forceps, or remove the crown by the file.
Some other operations more or less injurious have been pro-
posed for quieting the pain of the teeth and for preserving
them. Such as their luxation, extraction and replacement and
excision of their nerves ; but we hesitate not to say, that it is
more in accordance with the speculative spirit of the age than
with a healthful practice that these ideas have been advocated
we do not think that the above should be adopted as general
rules of practice.
Exostosis and Spina- Ventosa.
Under the name of exostosis we designate hard immovable
180 ANATOMY, ORTHOPEDIA,
tumors, which develope themselves upon the surface of bones,
and which it is beUeved are formed by a swelling, and consist
of a true hypertrophied condition of their tissue. The teeth are
subject to this affection, but the great degree of analogy which
exist between the bones in general, and the roots of the teeth,
explains why these last are most ordinarily affected. We say
the most ordinarily because there exists examples of exostosis
even upon the crowns ; we have seen a large incisor upon the
anterior face of the crown of which there is a sort of node raised
upon the enamel ; the person to whom this tooth belongs has
observed the gradual development of this deformity, and used
efforts to arrest the pains which if occasioned by the enlarge-
ment of the alveolus, upon the circle of which the enlargement
in its progress toward the root has encroached.
The cause of this swelling of the teeth, when it affects the
roots, is very obscure and difficult to perceive before extraction.
It exists sometimes only upon the side of the tooth, which pre-
sents a rounded or angular form, and, in some cases, it occupies
the whole circle and height of the root ; in other cases it accom-
panies the consumption of the root. This disease, of which we
possess a great number of examples in our pathological col-
lection, is nearly always the result of engorgement and the
ossification of the dental periosteum. It may exist when
the crowns are healthy, but it more frequently manifests
itself upon subjects whose teeth have become painful, either
from indolent inflammation, caused by the decay of the body of
the tooth, and which extends even to the roots, or is the result
of a gouty or rheumatic diathesis.
It is difficult to prove, in an exact manner, the existence of
exostosis of the roots, for it never causes suppuration, and the
gum nearly always continues in a healthy state. It may be in-
ferred from the severe pain which accompanies it, pain whose
intensity is not always the same, and which, in every case, an-
nounces itself after it has acquired considerable size; then the
alveolus becomes enlarged by the pressure of the diseased root
upon its walls, and this either becomes movable or is forced out
by the alveoli, and passes beyond the level of the neighboring
tooth, at which point it is altogether opposed to mastication.
PATHOLOGY AND THERAPEUTICS. 181
Some persons, says Fox, with reason, attribute this kind of
deformation to congenital vice of conformation of the root, but
as it differs very much from all the defects that the different or
badly formed roots of the teeth that are not diseased present, one
is compelled to believe that the cause is not a morbid action
which occasions an osseous deposit, as in all the other cases of
exostosis.
All that art can do in this disease, is to seek, when the pain
exists, to combat it by the three odontalgic remedies which we
have described in the course of this chapter, local bleeding and
topical emolients, narcotic medicines and revulsants. But if the
pain continues, so that the tooth becomes loosened, or by its
sweUing occasions a perceivable deformity, it is necessary to ex-
tract it. The example given by Fox,* proves that to delay this
operation is prejudicial to those who are affected with this dis-
ease. But in doing this we should be careful not to confound
it with rheumatic affections of the jaws, and especially with the
alveolar arches, of which they are, however, often the seat, and
about which we shall soon speak.
As to spina-ventosa, it attacks principally the roots of the teeth,
but it differs from exostosis, as the swelling is not so compact,
but spongy and sometimes lamellar. The cavity of the diseased
root is enlarged, its opening is larger than in its normal state, its
thin wall seems to have been distended by injlation. This dis-
ease is very rare ; we do not possess a single example of it. It
is accompanied by the same symptoms as exostosis, and has the
same therapeutic indications.
Softening of the Teeth.
Although authors have made no mention of this disease, it
does, nevertheless, exist as an essential affection. The teeth af-
fected with it presents a cartilaginous consistence, denoting that,
under the influence of a cause whose nature it is difficult to de-
termine, are deprived of the earthy salts which enter into their
*This author relates the case of a lady, all of whose teeth he was obliged
to extract, one after another, because theii roots were exostosed.
182 ANATOMY, ORTHOPEDIA,
composition and are reduced to a parenchynea into themesches
of which they are deposited. Those teeth resemble bone which
have been in a concentrated acid ; a circumstance which might
confirm the opinion of those who assimilate teeth to bone.
We have met with many cases of this extraordinary disease;
one of the most curious was a young subject whose two small
molars, one on the right, the other on the left, were reduced to
the consistence of wax. Pressure exerted upon the crown
by the finger, was sufficient to make them undergo a very
evident change. We preserved them carefully as the only
well authenticated example of this affection, until we had occa-
sion, last year to speak of it to Dr. Sander, the ancient teacher
of cliniques at Rotterdam ; this honorable confrere assured us
he had met with a lady who had lost all her teeth from a soft-
ening of their tissue. We requested him to give the most pre-
cise particulars of this case. His reply, dated 10th of April,
1842, we here quote :
"Having arrived at Rotterdam, I spoke with the surgeon, A.
Nortier, who with me visited the lady, Madame D ; I was
confirmed that her teeth was in a complete softened condition ;
we could by taking the teeth between the thumb and finger
change their shape. Their consistence was similar to the ma-
terial which the glazier uses for fixing in glass. This lady, aged
more than sixty, was very scorbutic, her gums were swollen and
a fetid odor escaped from her mouth. She lost all her soft teeth
to the alveoli, and these were filled with soft matter, which be-
fore constituted their roots."
As this disease, habitually declared under a deterioration of
the general constitution, it is towards this last state that all our
therapeutic efforts should be directed ; the office of the dentist
in this case should be wholly confined to the extraction of the
teeth, as they are rendered by this transformation altogether use-
less, and very annoying.
Diseases of the Dental Pulp.
In the pathological view which we have presented of caries,
we have seen that the severe pain which sometimes accompa-
PATHOLOGY AND THERAPEUTICS. 183
nies this affection, is in general the result of its invasion of the
dental pulp. This pulp can, nevertheless, in some cases, be af-
fected without any traces of caries ; and this affection is either
an inflammation, a fungus, an ossification, or finally a pure neu-
ralgia.
1st. The inflammation of the pulp, in nosological language, is
called odontitis. It more frequently affects the teeth of adults
than those of children, and is generally more common in the com-
mencement of the caries or wearing away, than in advanced
stages of this disease, this inflammation is characterised by a
sharp pain which is increased by a blow upon the crown of the
tooth, and which does not extend at first to the gum or the jaw,
but toward the second or third day the inflammation and pain
reaches their structures, if however it does not progressively di-
minish ; then all the nerves of the face participates in this pain
and are pulsative. But the pulsations of the arteries of the pain-
ful side are much more accelerated and the beats stronger,
whilst in purely neuralgic pains they are only much stronger ;
sometimes, however, without taking this characteristic, the in-
flammation ceases altogether, and the disease only leaves its
traces by a species of bastard paralysis, which accompanies the
swelling of the gum. The pain is such that we are obliged to
extract the tooth. We perceive the dental pulp, at the extremi-
ty of the fang inflamed, tumefied and even sometimes suppu-
rated and gangrenous.
This is not expressing a baneful opinion, when we say that the
causes of this inflammation are sometimes the impressions of cold
and heat — sudden changes of temperature — violent shocks upon
healthy teeth or light blows upon those decayed, or the retention
of alimentary particles in the decayed portion of the tooth, or
finally a metastasis of disease from other parts. This last cause
wants especial attention ; for it is to this we can bring to bear a
great number of very intense odontalgics, which are completely
rebellious to the means which might not be appropriated to their
special use. It is thus that we have seen a young man a prey
to the most agonizing pain of the teeth, and who submitted to
have four, successively, extracted without relief, and which
yielded only to a nasal haemorrhage, to which ho was accustom-
184 ANATOMY, ORTHOPEDIA,
ed, which was effected by powders inhaled for the purpose of
irritating the mucous membrane of the nares.
As to the treatment of odontitis, it ought to be in conformity
with the rules for caries, either anti-phlogistic or anti-spasmodic,
or over-exciting, or, finally, escharotic. We will confine our-
selves to noticing this inflammation in its most ordinary forms,
under its least dangerous character ; it often happens, as we
shall see in speaking of dental neuralgia, properly so called, that
the inflammation of the pulp increases the size of the nerve be
longing to the tooth, and even affects the brain at the point
where this nerve arises, and occasions sympathetic affections in
the parts to which the fifth pair of nerves are distributed, or
cerebral accidents of a serious nature, against which the extrac-
tion of the tooth, which was the primitive point of pain, in most
cases, is altogether useless.
2d. When the dental canal has been dilated by disease, or
finds itself accidentally opened, the soft parts which it enclosed
may be the seat of a fungus. If the canal has been dilated
towards the extremity of the root of the tooth, the tumefied pulp
becomes consistent, reddens, and forms a cord larger than when
in a natural state of health, and in this condition remains, with
a thickened alveolar membrane.
When the canal is opened by caries or fracture, there appears
exteriorly, on the pulp, a small red tumor, bounded by the edges of
the cavity of the tooth, and very sensible to the contact of for-
eign bodies. This sensibility is sometimes such, that mastica-
tion is not only impossible on the diseased side, but the patient
dares not even close the mouth, for fear that the corresponding
tooth, from above or below, should strike upon the fungus.
It happens often that this tumor becomes hardened, falls, and
of itself disappears. In cases where this advantageous result
does not take place, art should not fail to effect it. It can be
effected by excising the fungus, or cauterising it; or, when
these means have been used without success, it should be ex-
tracted.
The dental pulp may be, as we have said, independent of the
inflanmtiation and the fungus, the seat of a true ossification
which IS caused by two means : either when the tooth is worn
PATHOLOGY AND THERAPEUl'ICS. 185
off, then the pulp is ossified at its contact with the table which
closes the dental canal ; or, when the tooth is decayed, the ex-
tremity of the pulp terminates by a bony fibre, which remains
suspended to this pulp; for, assuming a pathological state, this
ossification, according to the judicious remarks of Mayelin, is the
result of a beneficent foresight of nature ; for, in the case of
wearing away of the bony plate of the tooth, it becomes adherent
to it, and augments its thickness ; in the case of caries, it closes
tlie cavity, and prevents the denudation of the parts contained
in the dental canal.
But it often happens that this bony fibre prolongs itself in the
interior of the canal, compresses the pulp, and occasions the pains,
the cause of which it is difliciilt to determine at first. It is that
which we have observed many times, as Rousseau expresses in
these words:* "A young man, of about thirty years of age,
being tormented with very violent pains in his teeth, presented
himself to me, in order to have the tooth extracted, which he
believed was the cause of his sufferings. This tooth was not
affected by caries, and, in the mean time, 1 endeavored to con-
vince myself that this was the principal seat of the pain. I ex-
tracted it; not having been able to discover any change in it, 1
broke it in order to examine the interior, and I found, in the
dental cavity, a bony fibre of considerable size. I perceived,
then, that this fibre, by its continued growth, irritated the ner-
vous pulp, and pressed it against the walls of the cavity, had
caused an inflammation, and was the evident cause of the pains
which this young man was a prey to for so long a time."
This case appears much more frequently than it is believed,
even at the present day. We find a remarkable one in an
Italian collection.! It is thus stated : "An Italian lady expe-
rienced a continual glowing or tingling in her left ear, which
appeared to increase daily, and which she compared to the noise
of a bell. This obstinate sensation having resisted every reme-
dy, this lady became very sad and hysterical. She had recourse,
finally, to Dr. Buzzi, dentist to the court of Tuscany. This
* Work quoted, page 257.
t Medic. Observ. Naples, l&i December, 1833.
24
186 ANATOMY, ORTHOPEDIA.
physician examined, with the greatest attention, the external
auditory passage, the Eustachian tube, and the buccal cavity,
and discovered no derangement there. He perceived no caries
upon the teeth, which he examined very carefully ; nevertheless,
he pierced each, and when he came to the left canine of the
upper jaw, the lady perceived the tingling sensation. Regard-
ing, then, this tooth as the seat of the disease, Dr. Buzzi ex-
tracted it, and immediately the lady was freed of a disease
which had, for a long time, tormented her without ceasing. He
cut the tooth in two, lengthwise, and found, in its interior
cavity, a small bony fibre, suspended to the nutritive artery, and
similar to the clapper of a bell."
Nervous or Dental Neuralgia.
Independent of the different kinds of pain which determine,
in the dental system, the different diseases that we have treated
of, and which have their primitive seat in the diseased tooth,
that is to say, which proceed from the periphery to the centre,
the teeth present others, which have no very apparent cause,
proceeding from the centre to the periphery, which is dependent
upon a direct lesion, either of the nerves distributed to these
organs, or from that part of the brain from whence these nerves
originate.
The first are generally of an inflammatory nature; the second,
on the contrary, are nervous, and consequently auxiliary, and,
in strict medical language, we should give them the name of
odontalgics. Thus, while some are of an inflammatory nature,
which discloses their usual progress, their throbbing sensation,
and the rate of the individual they affect, which are ordinarily
men, adults, robust and sanguine subjects ; the others are fol-
lowed, on the other hand, by a brisk and unexpected action,
are not usually accompanied by arterial beatings, often take an
intermittent form, and principally affect susceptible individuals,
who have suffered from long disease, hysterical women, finally,
persons tormented with rheumatic affections and transcurrent
nervous diseases, which have a strange analogy to rheumatism,
and which we commonly designate rheumatic pains.
PATHOLOGY AND THERAPEUTICS. 187
In the odontalgia which we have already spoken of, by the
percussion of the teeth upon the place where the pain is felt, we
at once ascertain which is the diseased organ ; in those in which
there is doubt, this method of examination is sufficient only to
prove that all the dental range on one side is affected at once.
There, all the phenomena are concentrated upon a single point;
here, sharp sympathies are put in action ; these are otites, tic-
douloureux of the face, in a word, phenomena which prove that
different divisions of nerves, of the fifth pair, are affected.
Thus, as a consequence of this fact, and of those that we have
given, whilst the extraction of the diseased teeth, in the case of
inflammatory odontalgy, causes the pain to cease, in nervous
odontalgia this extraction is a useless operation.
Some dentists, being ignorant of this distinction, daily com-
mit horrible mutilations, and compromise an art, which, properly
attended to, would conduct to the best results. Nevertheless,
we acknowledge that elementary works, written at the present
day, upon this art, are far from having established this distinc-
tion, since some of them have not even suspected it; but, in
reading with more attention the general treatises of surgery,
dentists might have avoided this error. There, in place of seek-
ing to calm all dental pains by local means which we have de-
scribed, they would seek, at early periods, to employ means
more appropriate to the nature of the disease, as revulsives, and
applying sinapisms to the legs, or very cold pediluvia, applying
cups to the nape of the neck, or even upon the cheek, bark or
sulphate of quinine in large doses, narcotics, such as opii, bella-
donna, ether, &c.
Benjamin Bell, an English surgeon, a member of the college
of surgeons of Ireland and Edinburg, has confessed the distinc-
tion that we have made; he expresses himself thus:* "Under
certain circumstances, we perceive that the pain from the tooth
depends upon an affection of another part and no remedy will
succeed, unless directed towards the primitive disease. Rheu-
matism is sometimes the source of the disease, or arthritic
* A Complete Course of Theoretical and Practical Surgery, translated by
Ed. Bosquillon, 1796, vol. 4, page 181.
188 ANATOMY OHTMOPEDIA,
diathesis ; it is often the synipt(ini of hysteric afTections which
pregnant woiwni are subject to ; it frequently depends upon a
disordered stale of the stomach.
Among the sympathetic affections which determine dental
neuralgia, there are none which are more frequent than those
which have their seat in the organ of hearing. These changes
sometimes have a most fatal result, as the following proves,
which has been related to us by Dr. Meleg, formerly of the
school of Strasburg.
"A young boy, of a good constitution, presented himself at
the venereal hospital of Strasbnrg, affected with a blennoragia
and itching. The treatment of these two affections were prompt-
ly conducted, but with much prudence. At the end of a few
days, a very severe od ontalgia manifested itself; fisver, headache,
beating of tlie temporal arteries, &c. followed. He was bled
copiously, but this had but little effect; we then extracted the
decayed and painful tooth. Then pains in the ear appeared,
which we endeavored to appease by applying leeches to the
mastoid apophysis ; but the toothache continued, and the pain
extended to the whole of the lower jaw, accompanied by loss of
rest, incubus, frightful dreams, and sharp cries. The violent
pains of the ear continued, and assumed the character of a noise
like that produced by the blows of a haunner upon an anvil.
Six days elapsed, but he still suffered the most agonizing pain.
He was now seized by so furious a delirium, that no one could
approach him. Although the auditory canal was healthy, all
the teguments of the ear and temples were so tender, that the
most light contact with them produced the most agonizing
pains. The delirium and fever continued, accompanied by
spasmodic motions of this lines, great dilation of the pupils of
the eye, continued weeping, rattling in the throat, a lethargic
state, and, finally, the death of the patient, after eight days of
the most excruciating sufferings.
"On opening the subject, the brain was found penetrated by
a general vascular injection ; in some places its substance was
similar to sand ; tiie dura mater, corresponding to rock, pre-
sented a remarkable redness, and was lightly raised in reference
to the superior semicircular canal. The incision of the mem-
PATHOLOGY AND THERAPEUTICS, 189
M
brane caused a small quantity of reddish and clotted pus to
flow. After having washed the surface, we perceived that the
walls of the canal were decayed, and that they had evidently
communication with the labyrinthial cavities in which the pus
had formed which flowed from the dura mater. Moreover, the
pus had the same consistence that the morbid products which
are found in the interior of the ear, whose membranes were red,
thick, and seenied softened. The middle ear appeared un-
touched ; on examining the mouth, we found many of the teeth
decayed only at their roots^
It might be asked, what was the primitive cause of all these
disorders? We do not hesitate to admit that odontalgia was.
The pain which accompanies it increases, and is propagated to
the brain, and is limited by causing, in this last organ, a primitive
sympathetic disturbance, but which, under the incessant action
of the odontalgia, locates itself in the cerebral centre, and ra-
diates towards the internal ear, where it locates itself with an
energy as much greater, as the organ affected is more delicate,
and as the patient finds, in the noise of the great hospital, a
cause of excitement sufficient to aggravate his disease ; for every
one knows how prejudicial noise is to persons affected with
otitis.
That sympathy so intimate which unites the dental apparel
to the organs of the ear has, however, been noticed long since;
thus Hard, Deleau,and most physicians which are occupied in
a particular manner with diseases of the ear have often sought
to prove the original cause of nervous surdities, which date their
first existence from a primitive and concurrent injury of the
dental apparel. No author, however, has given a satisfactory
explanation. Jobert says, in reference to this subject;* "we
should, nevertheless, seek an explanation of this fact from the
anatomical arrangement of the different parts. Examine, then,
the relation between the chorda tympani and the dental and
lingual nerves, as the termination of this same chorda tympani
as in the facial nerve, of which it appears to be only a branch ;
notice, then, the anastomosis of this last nerve with the acoustic
♦Sludies upon tlie Nervous System.
190 ANATOMY, QRTHOPEDIA,
»
nerve in the internal auditory channel, and you will probably
be in the right track. I believe, in effect, that is the result of
the nervous distribution that we can attribute the surdity which
accompanies the phenomena of dentition."
This explanation, says Mueg,* seems to lack exactness. It
is established daily, that the anastomosis are only of juxta posi-
tions ; that the nervous fibres, after the reunion of the two roots
never unite together; they proceed separately, and independent
of each other ; and that, consequently, there can never be the
least conflict between them, excepting in the case of nervous
sympathy. (We have already made this observation on page
257, in speaking of the proposition that Malgaigne makes in
order to destroy the nerve which belongs to one tooth in order
to calm the pain which is felt in the preceding one.) We draw
two conclusions from thence ; first, that the pain neither irritates
it, pathologically, or mechanically, nor can it transmit itself to
the different organs by the anastomosis of their nerves ; second-
ly, that each time that a pain co-exists sympathetically in a part
with the pain of another region more or less distant, it manifests
itself by a reaction of the nervous centres. We can thus ex-
plain perfectly the auricular sufferings which so often accom-
pany odontalgia, and vice versa ; hence these always result from
the phenomena of reflection."
We may now definitely conclude that all the pains which are
felt about the teeth are only the result of a physical alteration of
their substance ; that, whatever may be the cause from whence
they proceed, they may radiate towards the brain and produce
serious effects ; finally, that the dentist who employs no other
means but extraction, will sometimes be exposed.
In every case, when a dental pain is evidently of a nervous
nature, two kinds of means present themselves for our consider-
ation ; the one is under the jurisdiction of the medical matter,
the other belongs to the operative physician. The first are
placed in the numerous class of anti-spasmodics, as opium, which
is principally administered under the form of salts (acetate or
* Of Electricity applied/or the cure of Surdily, Review of Specialities, Sep-
tember, 1842.
PATHOLOGY AND THERAPEUTICS. 191
hydro- chlorate of morphia) by the endermic method, that is,
by the deprivation of the skin of its epidermis, in doses of from
the fifth of a grain to a grain ; henbane, datura stramonium, bel-
ladona, that Deleau pretends to have employed, with the great-
est success, under the form of cataplasms, in all neuralgic affec-
tions of the face; afterwards the asafoetida, cherry leaves;
finally, he employed cups, blisters, by the epidermic method, that
is to say, after having deprived the skin of its epidermis, to ad-
minister doses of from the fifth of a grain to a grain ; Deleau
pretends to have employed with the greatest success under the
form of cataplasms, in all facial neuralgics, as guiacum, datura
stramonium and belladona ; afterwards, asafoetida, cherry leaves ;
finally, blisters, cups, moxas, etc. If, as is sometimes the case,
the pain takes an intermittent form, Ave should not hesitate to
administer sulphate of quinine.
Another means which belong to operative medicine, and
which should never be employed unless the first have failed,
consists in separating the dental nerve from the common trunks
which are the superior and inferior maxillary nerves. The first
we attack at the point it leaves the sub-orbitary foramen by cut-
ting it in the interior of the mouth, or, to speak clearer, towards
the internal face of the lips or cheeks by a simple puncture or
by an incision as recommended by the elder Berad ; and the
second according to the directions of Warren, Velpeau,the elder
Berad, Malgaigne, to the works of which we refer, persuading
dentists at the same time not to take upon themselves the re-
sponsibihty of similar operations.
PHYSICAL CHANGES OF THE TEETH.
The Wearing Away of tlie Teeth.
The wearing away of the teeth, considered in itself, properly
called is not a disease ; it constitues rather physiological pheno-
mena, which is the inevitable consequence of the exercise of
these organs. It is not only when the wearing shows itself
among young subjects, and when it progresses with rapidity, or
when the destruction of the teeth amongst more aged persons, is
192 ANATOMY, ORTHOPEDIA,
sufficiently great as to give place to accidents, that it should
merit the attention of the pathologist.
In wearing away, the teeth diminish in fieight in proportion
as they are employed. This diminution, show amongst all in-
dividuals whose dental apparel is complete, regular and well
situated, is much more rapid among those who wear a greater
or less number of their teeth (those which being well arranged
are submitted to more frequent use) or among those who have
them badly arranged.
Numerous circumstances contribute to cause the wearing
away of the teeth ; such are, as predisposing and occasional
causes, then friction during mastication, their delicate texture,
the chemical influence that certain aliments exert upon them,
the employment of certain dentifrices which are not well
ground, that of acids, the use of earthen pipes, which should
always be furnished with fine wires, the habit of chewing upon
one side, the action of breaking hard bodies in the mouth, the
grinding of the teeth resulting from a convulsive action of the
muscles of the jaw, that we observe principally among persons
during sleep, &c.
Wearing attacks particularly the parts which touch in the
meeting of the alveolar arches. Thus, we observe it principal-
ly upon the triturating surfaces of the molars, upon the anterior
parts of the superior incisors and upon the posterior of the infe-
rior incisors ; when the first generally, as we have often remark-
ed, have deviated inwardly from the line representing the curve
of the alveolar arch. In order to be convinced, the touching of
the teeth is the principal cause of their wearing away, it is only
necessary to examine the state, even at a very advanced age, of
the incisors of that species of bull dogs, whose inferior jaw
makes a large projection outwardly to the superior. These teeth
preserve at all times the form of a Jieu de lis. Now, we know
that, in the canine species this conformation of the incisors is
regarded as an indication of youth, and its disparity as a more
equivocal sign of the contrary position. This form undoubted-
ly disappears because the continual contact of the teeth, either
between themselves or between them and other hard bodies, has
worn only the tubercle or projection the union of which three
forms the flue de lis.
PATHOLOGY AND THERAPEUTICS. 193
Besides, particular circumstances often vary the manner by
which the teeth are worn away ; we have observed, that the
incisors are worn away more rapidly when the molars are
wanting ; and the same is often the case, cmteris paribus, with
the latter. As abrasion of the teeth is common to all, and as it
increases with years, it would seem probable that inductions
hence might be drawn, with regard to the age of individuals;
but this is not the case, because it is caused either by irregu-
larity of the teeth, as in the case of which we are about to speak,
or by the difference of food ; it exists among persons who have
suffered the loss of a considerable portion of the substance of
their teeth at an early age, whilst among others this loss is
scarcely manifest, even at an advanced age.*
Although the wearing away of the teeth is not rendered very
evident until advanced age, it is no less true that it no more
spares infancy than old age. In effect, if we examine the teeth
of a young subject, whose first permanent molar has appeared,
and if we compare it with the neighboring milk molar, which
should be immediately replaced, we see that the tubercles of
the first are elevated much above the deep sinuosities which
separate them, whilst those of the other have entirely disap-
peared, or are nearly level with the rest of the surface, and only
present between them imperceptible sinuosities. These sinu-
osities have a yellow and dull color, whilst the parts which
surround them are of a brilliant white ; this is of the greatest
importance to be known, in order to prevent mistakes in ex-
traction. Whilst the enamel is not destroyed, the triturating
surfaces of the teeth remain white; but when the ivory can be
perceived, we observe, at first, in the centre of each tubercle of
the crown, a yellow spot, which gradually enlarges, until the
layers of enamel disappear; the tooth then presents nothing
more than a flat surface, more or less unequal, of a yellow color,
* In veterinary medicine, this wearing away is the index most con-
stantly consulted, principally in the horse species, for determining age. But
horses being accustomed, generally, to the same kind of food and care, the
wearing away of their teeth ought to be the same among them. This
opinion, however, has often caused serious errors to be committed,
25
194 ANATOMY, ORTHOPEDIA,
its circumference bordered with enamel, and leaving, in the
direction of the dental canal, a spot of a deep yellow or blackish
color.
The first indications of the wearing away of the teeth are, a
great sensibility, a setting on edge easily by acid or sweet sub-
stances, and by impressions of heat and cold. In proportion as
it increases, the sensibility becomes more intense, and some-
times replaced by incessant pains. If the individual has very
delicate teeth, if the painful impressions are renewed too fre-
quently and with too great intensity, the dental pulp participates
with this morbid state ; it inflames and suppurates ; from thence
follow very acute pains, and an inflammatory swelling of the
neighboring parts, which the meeting of the jaws increases, and
which yield only to extraction.
These are more common than one might believe. Most
commonly, it is limited by exciting the functions of the pulp,
which, stimulated then, assumes a greater vitality, and preludes
a kind of bony cicatrization, consisting of a deposit, in the inte-
rior of the dental cavity, of an earthy substance, which strength-
ens the ivory by a new interior layer. This new substance, of
which we have already spoken of in the ossification of the pulp,
which forms and increases principally upon the side of the
worn part, and which Rousseau names the osselet, was already
known to Hunter and described by others.
It absolutely resembles the other parts of the teeth ; some-
times more yellow, yet it is always as transparent and as brittle;
it assumes no regular structure, detaches itself from the dental
cavity, and isolates itself altogether from it, and the sides which
correspond to this cavity are much more dense than its interior sur-
face. The portions of worn teeth are then reproduced ; but this
addition of osseous substance is a cause, often, of their destruc-
tion without pain. It is in consequence of this addition, which
insensibly takes the place of the stony pulp, and which, in fill-
ing the cavity, destroys the sensibility of the teeth, that old
men are less subject than young to dental pains, or have these
pains infinitely less intense, because, amongst them, the central
canal is not penetrated by the air, nor by other strange bodies.
We say, that the parts of teeth that are worn away are not
PATHOLOGY AND THERAPEUTICS. 195
reproduced ; consequently, for the treatment of this, it is not
only necessary to remedy the loss, but to suspend and destroy
the cause which occasions it. Thus, when a tooth is worn
away by the friction against the opposite one, we can diminish
this last by the file ; this is applied principally to the incisors or
canines. The different forms which abrasion gives to the teeth
produce irregularities which injure the neighboring parts ; it is
necessary to remove them by the same means. We advise, that
as such dentifrices as may be too rough, and such drinks as may
be too acid in their nature, and which may be the cause of the
wearing away of the teeth, that they should not be employed.
But if the tooth becomes too much worn, or too painful, we
might perforate the dental cavity, and afterwards plug it; and
if this operation is impossible, we might cauterize the crown
of the tooth, which would remain then insensible. As to per-
sons subject to grinding their teeth during sleep, they affirm
that if they place a piece of linen, cork or any other hard sub-
stance between their jaws, in the night, that they can avoid the
consequences.
Cracks and Fractures of the Teeth.
Cracks in the teeth, which are, to speak plainly, but a small
fracture, causes no morbid change, for it is superficial. A num-
ber of causes produce it ; they are, perhaps, occasioned by the
grinding of the teeth, by convulsions,* by the contact with hard
bodies during mastication ; sometimes, by the effort exerted by
the jaws to break hard substances ; sometimes by blows and
by falls. The pain, at the moment that the crack takes place,
is more or less severe, according as the loss of substance is more
or less great ; afterwards, for some time, it is more or less sensi-
ble of impressions of cold, heat, acids, or by the contact of hard
bodies. We can limit, as in certain cases of the wearing away
of the teeth, the fractures of the teeth, by filing their angles, in
* We have seen, in a house of health, a young lady of fourteen years,
affected with general convulsions, which were so violent and tumultuous to
the jaws, that after some days the whoje cutting edge of the anterior teeth
had successively disappeared by fractures.
196 ANATOMY, ORTHOPEDIA,
order to prevent them from cutting the soft parts of the mouth,
and also in order to give the teeth a more regular appearance.
Whatever resistance the texture of the teeth may offer, they
are, nevertheless, susceptible of being completely broken by
fractures, not only in consequence of exterior violence, as a blow,
a fall upon the face, and an improper attachment of artificial
teeth ; but still by the simple closing of the mouth, by the
compression of the jaws, etc.
Most ordinarily, it is true, they possess a predisposing cause
to this accident, in constitutional disease, as the scurvy, rickets,
scrofula, syphilis, or any other affection capable of breaking
them, or in a local affection, as caries, atrophy. Sometimes we
see healthy teeth fractured crosswise, without any apparent
cause. Laveran gives an example of a small molar. Duval
has also observed, upon a man of sixty years of age, the two
bicuspides of the superior jaw fractured lengthwise, without
a blow or without pain : we ourselves have met with similar
instances.
As for the rest, a tooth may be fractured at its crown, at its
neck, or at its root; the fracture may be complete or incomplete ;
take a longitudinal, transversal or oblique direction ; finally,
it may be simple or complicated, that is to say, exempt from or
accompanied by the contusion of the neighboring bony or soft
parts.
Some ancient authors thought that a fractured tooth cannot
be ossified. They say, the teeth are exposed to the action of the
air, and of the surrounding cold airman obstacle in the formation
of osseous matter. They add, no aggulifiative fluid can Jlota
from the teeth, on account of the dryness of their substance ; or,
if it flows from them, it is very much diluted, and has not the
necessary qualities for consolidating the parts, on account of their
small quantity of heat.
This explanation proves they were far from entertaining an
exact view of the manner by which the two fragments of a
broken bone may be consolidated ; besides, it applies only to
the crown of the tooth, the only part which may be affectedly,
and exposed to the cold of the surrounding air ; finally, it rests
upon a fact which the researches of Behu, Jourdain, and, more
PATHOLOGY AND THERAPEUTICS.
1^7
recently, those of Duval, etc., have proved erroneous; they
have demonstrated, in an incontestable manner, by experiments
upon living animals, that the fractures of the crowns can, as
well as of the roots, be consolidated. The procedure which
nature employs to effect this end, differs, nevertheless, from
what we observe in the union of fractured bones ; that which
exists in the difference of organization between the teeth and
other osseous structures ; the adhesion of the fragments of teeth
is not effected between their extremities, but results, universal-
ly, from the formation of new layers of ivory, furnished by the
pulp, which layers extend themselves between the parts, in order
that they may unite themselves, as it were, mechanically to-
gether.
The result of these observations is, that in order that adhesion
may take place, it is indispensable that the fractured parts re-
main in contact with the pulp, and that this tissue does not
suffer too great a change. It is not, then, affected by a cicatrix
of dental bone; this is so true, that when a space exists be-
tween the fractured extremities, the union is effected no less by
it, although the primitive separation exists.
Fractured teeth are more susceptible to the action of external
agents than those which have been simply cracked. This sus-
ceptibility, sometimes so great as to be attended by pain, exists
to an indefinite period after the fracture has taken place, and
even extends upon the layers of ivory furnished to the interior
of the tooth, by the pulp, have been completely developed. As
to the rest, teeth which have experienced the action which we
have described, lose their brilliancy, and become yellow or
black: it is, nevertheless, to be remarked, that they seldom
decay, unless a cavity is formed by the fracture.
The superior incisors are the most subject to fractures, be-
cause their position exposes them most frequently to mechanical
injuries from without. When the fracture is small, consisting
of a simple crack, the greatest inconvenience resulting from it
is, that it causes asperities capable of irritating the neighboring
parts ; it is always easy to remove them, by using the file. If
the loss of the enamel injures the form of the crown, and ren-
ders it necessarily less fitted to perform its functions, it, how-
198 ANATOMY, ORTHOPEDIA,
ever, does not draw, as we know, the loss from the tooth,
although it can lessen much of its hardness, and become broken
by a premature age.
It is not necessary to believe, as some authors, that the loss
of the substance of the teeth always has an injurious effect.
Fox principally considers the enamel as not being absolutely
indispensable to their preservation. To strengthen this opinion,
he quotes examples from many savages of India and the interior
of Africa, who are in the habit of giving to their incisors a
strange form, and that of individuals, who, after having filed
their teeth, have preserved them to old age.
These examples prove nothing, if only superficial changes of
the enamel are not always injurious, although, in the part we
have devoted to caries, we have proven the necessity of sepa-
rating teeth with a file, for the removal of caries. But it, at the
same time, establishes the principle that, in all cases where
great portions of the crown of a tooth have been fractured, it
constitutes a serious injury, which, sooner or later, results in
the destruction of the injured organ. We can even, in order to
prove that we do not exaggerate more the innocence than the
danger of the loss of the enamel, quote examples given by Fox,
of caries which affect the teeth of the Malay Indians, after
having had horizontal grooves cut across the anterior surfaces of
their crowns.
It is principally where the ivory is exposed to the action of
external agents, that fractures, when of considerable extent, be-
come dangerous. As to the means which art has to oppose
their effects, they vary according to the nature and extent of
the fracture. If the fracture is confined to the crown, without
extending to the pulp, the tooth can be preserved ; it is, how-
ever, necessary to guard against inflammation, which may de-
velope itself, for if this occurs, the tooth may become the seat of
excessive sensibility, which it is necessary to remove imme-
diately, by cauterizing the fractured surface. The deformity
which might result from it may be corrected, by slightly dimin-
ishing with a file the height of the adjoining teeth, if that can
be done without danger. When the pulp is almost entirely ex-
posed, cauterization is still more necessary; afterwards the tooth
should be plugged.
PATHOLOGY AND THERAPEUTICS. 199
When the fracture extends to the neck of the tooth, which is
always a serious accident, and always causes great local disor-
der, independent of the most acute pain, the procedure of the
dentist should vary according to the age of the patient. If an
adult, after having subdued the inflammation, it should be cau-
terized with a red iron ; then, after some days, the root should
be filed to a level with the gum, and either plugged or a tooth
engrafted on it.
But if the subject is young, this procedure, in most cases,
would be a feeble resource, for the teeth at this time possess a
vitality which renders them very susceptible to the action of
foreign bodies ; besides, their roots are not completely develop-
ed ; they may then become the seat of different affections
which hasten their loss ; it would, then, be very hazardous to
attempt to preserve them at a later period, by inserting artificial
teeth. This is an important branch of practice ; we recommend
it to the attention of our professional brethren ; experience will
prove that the most rational course among young subjects, is to
extract the tooth. The space caused by it will gradually disap-
pear by the approximation of the adjoining teeth, but if it should
remain, it will be but a slight inconvenience compared with that
which would result from the presence of a foreign body, as a
plug or false tooth, introduced into a root possessing great vitality.
With regard to fractures which extend lengthwise to the root,
we should not hesitate for a moment to extract the loose pieces.
If we delay too long their removal, their presence in the alveolar
cavity will be the occasion of violent pain, inflammation, of ab-
scesses, and of other serious accidents, which will not subside
until the total extraction of the fractured tooth. If the crack does
not extend to the root, we can seek to unite the two divided parts
by a ligature, which will maintain them joined lengthwise, we
can then avoid the inflammation of the pulp and fistulous ab-
scesses.
Finally, in order to conclude this article, we say, furthermore,
that the fractures of roots are not always easy to be perceived ;
but they constitute, in every case, a serious accident, not by the
solution of continuity in itself, but by the injuries of the pulp
and of other parts contained in the alveoli, by which they are
200 ANATOMY, ORTHOPEDIA,
most ordinarily accompanied. Thus, the best course to take
as regards this, is to extract the tooth. Notwithstanding the
advice of some authors, who, as we have already said, have
pretended that these fractures can be consolidated, and the ob-
servations upon which they support them, we still advise, in
these cases, the rules which we have given to be followed, and
which, being applicable, if not universally, at least in most
cases, will always provide against grave errors.
Concerning Accidental Luxation of the Teeth.
The causes which occasion the fracture of the teeth can, with-
out doubt, act in a less degree than those which cause a solu-
tion of continuity. Then, in place of breaking, the tooth expe-
riences but a simple displacement, that is to say, changed in-
wardly or outwardly, and departs more or less from its alveolus.
This displacement may be simple, or complicated by contusions,
by wounds of the gums, by fractures of the alveolar borders,
and even of the jaws. The incisors and canines are more ex-
posed to luxation than the others. There are two reasons to
account for this : the first is, that, though firmly implanted,
having but one root, they yield easily to the influence of exterior
violence ; the second is, owing to their situation, they are less
protected than the others.
These luxations may be complete or incomplete. In the
first instance, all the treatment, as good sense merely shows, is
to replace the tooth in its primitive position, and to secure it
there by a ligature, being careful, at the same time, not to attach
it to the adjoining teeth, which might soon become so unsteady
that they would be placed in an inflammatory centre, but either
to the second or third.
If we have reason to believe that, in the various movements
of the jaw, this luxated tooth will come in contact with the op-
posite one, it will be necessary to remedy this by applying a
light plate of platina, of gold, or any other substance upon the
neighboring teeth, to prevent the meeting of the jaws. During
the first week liquid aliments should be used, and during the
second, aliments easy to be masticated ; this will assist in the
PATHOLOGY AND THERAPEUTICS. 201
consolidation of the teeth, which is not sometimes accomphshed
for a fortnight.
We have treated merely of simple luxation, but the case may-
be more serious, and extend even to the raising of the tooth,
with the complete destruction of the natural adherences which
retain it in its alveolus; that which occurs, for example, when a
dentist extracts one tooth for another. His conduct here should
be the same as in the preceding case ; it is necessary, after hav-
ing examined the mouth with care, to replace the tooth, and to
wait, not that he may take nourishment, as is customary, how-
ever, among some practitioners,* but that the surrounding parts
may be adapted to it, in order that it may solidify, as in the
natural state. That which convinces us that a tooth implanted
has ceased to live, is, that it takes a yellow or dull grey tint very
soon ; for the pain that it seems to feel when we pierce it, is
the effect that the shock determines in the neighboring parts,
but not the result, if we may speak thus, of a sensible vitality.
We shall treat again of this subject, in speaking of dental trans-
plantation.
It is nearly useless to observe that the consolidation of luxated
teeth is subordinate to two conditions : the age of the subject
and the state of the surrounding parts. To this effect, we know
that at twelve or fifteen years the orifice at the extremity of the
root allows the nerves and blood-vessels to penetrate it with a
facility which permits a free action upon the tissue of the tooth ;
we conceive, then, that if the luxation was the result of a frac-
ture of the alveoli, or of a violent contusion of the gums, the
inflammatory work which results from it will be more unfavora-
ble than propitious to the reunion of the separated parts. This
is the case with individuals of a bad constitution, whose gums
* Fox says he has seen a replaced tooth perfectly firm in its alveolus
six hours after having been extracted. Bell, who we have already quoted,
in treating of the different characters of dental pain, even believes the
possibility of the intimate union of a transplanted tooth; he expresses him-
self thus on this subject : "This operation is suitable only for young men
and adults, for it succeeds only, as it appears, when the tooth contracts a
direct union with the contiguous parts, by means of the blood-vessels
which communicate between them."
26
202 ANATOMY, ORTHOPEDIA,
are constantly bleeding or choked up, the replacement of the
luxated teeth, and, with a greater reason, those that have been
extracted, never has a favorable result; the first should be ex-
tracted, and the latter operation prudence would require us to
omit.
Of the Loosening of the Teeth.
Instead of being fractured or luxated, the teeth may simply
become unsteady or loosened in their sockets. The causes
wliich determine this accident are exterior or physical, interior
or constitutional.
Exterior causes are, as one would suppose, violences which
have not been sufficiently great to cause a fracture or luxation ;
to those causes it is necessary to add acts belonging to our art,
as a ligature or a brace improperly applied, a support badly taken,
and, finally, the incrustation of a tooth by tartar, which has ex-
tended even to the root, by introducing itself between its neck
and the gum.
The interior or constitutional causes are the different changes
which the softened and spongy gums experience by the effect
of a scorbutic or scrofulous diathesis, by a rheumatic or gouty
affection, by a severe disease, by the use of mercury, by inhabit-
ing places where the vapors exert an unfavorable chemical ac-
tion upon the teeth, and, finally, from many diseases of the
alveoli ; the critical age, among certain females, is sometimes,
also, the cause of it. But, of all, the most frequent is old age.
This difference in the causes of the vacillation of the teeth
draws from it one, necessarily, in the choice of the means to be
employed to remedy it. Is it the result only of accidental
causes, we confine ourselves to treating of local phenomena, to
prescribe the use of aliments easy of mastication, to warn the
patient of the danger he might experience in testing improperly
the solidity of his tooth by touching it with his finger or tongue ;
and we advise him to use, in the course of the day, many gar-
gles with water sharpened by a tonic sipatous liquor. If the
accident is occasioned by ligatures, bands or resorts, it is very
plain that their sohdification is subordinate to their removing;
it is the same case with tartar, that it is necessary to destroy.
PATHOLOGY AND THERAPEUTICS. 203
and of the excessive length of a corresponding tooth to that
which vacillates, which must, of necessity, be shortened.
Unfortunately, the process passed through is not as simple
when the teeth are loosened by an interior or constitutional
cause. This is the cause that must, before all, be opposed;
the teeth become tightened of themselves, by the treatment
which belongs to them. It is, nevertheless, nearly always
proper to second the efforts of nature by emollient lotions, tonics
or astringents, according as the parts which envelope the tooth
offer the appearance of a tumefaction, sponginess, or of an OBde-
matous swelling; forwe regard this assertion of Maury as an error,
or at least as a great exaggeration : that "the loosening of the
teeth may be considered as an affection which is dependent
rather upon the state of their tissue than upon that of the parts
with which they are in connection."
DISEASES OF THE DENTAL APPENDAGES.
Diseases of the Gums.
The gums are composed, as we know, of a very vascular sub-
stance, eminently susceptible of swelling, by the least irritation,
and which adheres to the necksof the teeth, which it surrounds
on all parts, as also the alveoli, whose exterior walls it en-
velopes.
When healthy, the gums are strongly attached to the teeth,
immediately above the alveoli, and their edges rest upon the
enamel. Firm and of a rose-white color in their natural state,
smooth and united in infancy, irregular and scolloped in the
adult; hard, resisting, semi-cartilaginous in old age, they not
only participate in the affections of the teeth, to which they are
united by intimate relations, but they are themselves subject to
many changes, of which the nature of their tissue and their
position explains the frequency, and in the course of which they
inflame, tumefy, ulcerate or produce excrescences.
Sometimes, as we know, the gums become the seat either of
more or less acute inflammations, which often terminate by sup-
purations, and give place to abscesses, or of apthas, pains, exco-
204 ANATOMY, ORTHOPFDIA.
nations, fistulas and of ulcerations ; sometimes they diminish
in volume, so as to scarcely cover the alveolar borders, or they
enlarge and swell, so as to give birth to fleshy excrescences,
that are often difficult to make disappear ; changes that, in order
for us to conform to the order generally adopted, we shall divide
in three sections : firstly, inflammations and swellings ; sec-
ondly, ulcerations ; thirdly, tumors, excrescences and fungi.
The first includes, therefore, inflammation, followed by the
perforation of the gums at the time of dentition, apthas, ab-
scesses called purules, suppurations, dental fistulas, to which Ave
have added abscesses of the maxillary sinus ; finally, the adher-
ence of the gums with the cheeks and lips. In the second, we
find scurvy of the gums, gangrene, different changes considered
as results of scrofula, of syphilitic virus, and of the use of
mercury.
Finally, the third section comprises a description of excres-
cences, designated under the name of epules, and of some other
tumors of the same nature.
Inflammatory Diseases of the Gums.
Of Inflammation of the Gums, resulting from the Cutting of
the Teeth. — In treating of the physiological phenomena of den-
tition, we have already designated the inflammation of the gums
as one of the ordinary accompaniments ; and, in the chapter
devoted to dental hygiene, we have described some of the prin-
cipal means for preventing it. But, whatever precaution we
may take, however good the constitution of the child, it is rare
that it does not experience some ill effects from it ; and we re-
peat it here, that no doubt may be left of our opinion regarding
it, although the frequence or at least the dangers of this inflam-
mation has been many times exaggerated, it is no less demon-
strated by experience, that it can, in some instances, be carried
to a degree capable of giving serious injuries.
We shall not return again here to the determining cause of
this phlegmasia. We are compelled, for many reasons, to regard
it as a consequence of the action of the teeth, which, being ele-
vated above their alveoli, advance and push towards the interior
PATHOLOGY AND THERAPEUTICS, 205
of the mouth through the gums, which are too httle disposed to
yield to this influence. We even believe this explanation as ap-
plicable to the cutting of the second as of the first teeth ; for if,
in this latter case, it resists so much as to prevent the eruption of
the teeth, in the first, being altogether more dense and hard, it is
less easily distended, particularly if the premature cutting of the
gum has cicatrized, which the permanent tooth, of necessity,
has to break through.
At one period or the other, the inflammation of the gums may
be so violent as to extend even to the face, and determines,
principally, either that which is commonly named fluxion, or a
similar state, upon the mucous membrane which lines the eye,
the internal ear, the nasal fossae, or a swelling of the sub-maxil-
lary glands, and of the lymphatic ganghons which surround the
neck. Accidents may be much more serious yet, especially at
the time of the cutting of the large molars of the inferior jaw, a
cutting which may cause extensive abscesses, which are, unfor-
tunately, liable to open exteriorly, and sometimes to invade the
maxillary bones. We also conceive that if this occurrence fol-
lows the eruption of the temporary teeth, it may cause the de-
struction of the germs of the permanent ones, and, by the ab-
sence of these last, change, as we have already said, the features
of the face.
In considering this inflammation only as the result of a me-
chanical cause, we necessarily simplify the treatment ; to soften
the swollen gum, or to open a passage for the tooth in the right
place, are, in first dentition, the two indications to be fulfilled.
It is principally with the milk of the mother, as all authors say,
that this softening is efl'ected. We find, from this, the means
of appeasing the thirst with which the infant is always torment-
ed, and of assuaging the local pain. If it is already weaned,
we must have recourse to the mucilage of flaxseed, gum
arable, althae, to which we add a little honey, and when the
gums are harder, with a small brush, or with a piece of the root
of althse, or with the finger.
If these means, employed a certain length of time, do not suc-
ceed, a passage must necessarily be opened for the tooth ; but
this operation, in order to meet with that success it should, is
206 ANATOMY, ORTHOPEDIA,
subjected to certain conditions of opportunity and execution,
which certain young practitioners are generally too disposed to
despise. We then repeat here, that the section of the gums is
indicated when they are very firm and hard ; it can be discover-
ed by touching it, and when we perceive, at the place of contact
of the tooth with the gum, a white spot, which is circumscribed
by the general redness of these latter.
The incision will be, on the contrary, contra-indicated, if the
gums are very much swollen, and if the inflammation is very
acute ; for besides, the pain, ccBteris paribus^ is much more in-
tense, the vessels being filled with blood, it may happen that a
section of them may occasion a haemorrhage, which, though in
general not very considerable, is sometimes embarrassing, either
by the difficulty of suppressing it, or by the trouble which is ex-
perienced from the blood flowing into the mouth or passing into
the stomach.
As to the manner of incising the gums, this is of some mo-
ment. Some authors, after having acknowledged the necessity
of the operation, pretend that a simple scratch, made with the
nail, is sufficient, and abandon it to the nurse. This is a gross
error, which common sense would at once refute. A simple
separation of the gums will not assuage the symptoms, or ac-
complish all that may be obtained from the resources of our art ;
it is even more capable of giving rise to evils than of remedying
those for the relief of which it is employed ; for experience
demonstrates that the unequal tearing of the soft parts, even of
those not inflamed, may occasion the most serious nervous dis-
orders. These lacerations are even true wounds, which do not
prevent accidents from having their course, nor does it re-
move them, because the tension of the periosteum will be often
an obstacle to the free cutting of the tooth. All observing prac-
titioners agree upon this point, that a simple incision is not
always sufficient to subdue the effects which result from the
tension that the gums experience from that part of the tooth that
seeks to make its way through it. John Hunter relates that,
being called upon to visit a child afiected with convulsions,
caused by a difficult dentition, and which had resisted ail the
anti-spasmodics, and most of the otlier means known ; he caused
PATHOLOGY AND THERAPEUTICS. 207
this alarming state to subside in less than a half hour, by scari-
fying the gums as far as the teeth. But as he did not extend
his incision sufficiently far, the gums cicatrised from the imme-
diate contact of the edges of these small wounds ; the teeth
continued to grow, and to increase beyond the space which the
scarifications had procured for them, the convulsions returned,
and he was obliged to renew his operation, which caused them
to subside as promptly as the first time. At the present time,
similar instances have been presented to us.
It is, then, important that the incision of the gum, inflamed
by the action of the tooth, should be well executed, that is to
say, completed. We believe that which is made by a crucial
incision is preferable to any other, because it better prevents a
reunion of the lips of the wound, and more easily permits the
excision of the shreds, which is often necessary to be practised,
in order to expose the tooth. We may, although some authors
say that they can determine what teeth this should be practised
upon, give the crucial form to this incision, provided we take
all the necessary precautions which the case requires. This
remark appears to us useful, in order to prevent practitioners
who are too timid, in equal cases, from submitting the child to
the difficulty for the cure of which he had practised the exci-
sion. We shall return again to the selection of the instruments
and the proper procedure of the operator.
Aphthce. — The ancients give this name to nearly all the su-
perficial inflammatory diseases of the mouth. We find, in effect
under this denomination, in their writings, simple erythema
psuedo-membranous afiections, exudations of a soft and cheesy
substance, true ulcerations and gangrenous eschar ; some have
still more augmented this confusion, by adding the gangrene to
this order of diseases.
But the actual state of pathological anatomy does not permit
us to confound, under a generic name, entirely different morbid
changes ; we have restricted the history of aphthce to all the
light phlegmasia of the mouth, of which we shall treat and
which name we will reserve for eruptions of vesicle or round
forms. Thus, then, we mean by aphtha, a kind of eruption of
superficial or profound whitish tubercles, which develope them
208 ANATOMY, ORTHOPKDIA,
selves particularly upon the mucous membrane lining the inter-
nal surface of the mouth, and which reaches, sometimes, the
vale of the palate, the tongue, the pharynx, and even the intes-
tinal canal, or air tubes.
This eruption commences by a small, transparent, white or
pearly vesicle. At the first, or as late as the second day of its
appearance, a grey or white swelling, hard at its base, developes
itself above and around the vesicle, and gives it the appearance
of a small pustule. This pustulous character developes itself
the second or third day, because the vesicle bursts and allows
the transparent liquid which it contains to escape, and is re-
placed by a more or less painful ulcer.
This second period of aphthas, which we might call the period
of ulceration or suppuration , is prolonged , ordinarily, many days,
and sometimes even one or two septennaries. During its con-
tinuance, the swelling it presses down by degrees into the level
of the surrounding parts ; the ulceration enlarges, and is limited
by a small red circle, which announces, ordinarily, the tendency
to cicatrization. This third period, viz. that of cicatrization,
proceeds very rapidly until the small ulceration is cleansed, and
often it is over that day or the one following, without leaving
any other trace upon the mucous membrane than a small red
spot, which soon disappears.
Such are the general characters of aphthae, which sometimes
is distinct and proceeds more or less rapidly ; again, on the con-
trary, it is conJlue7it, and proceeds slowly, that is, it is stationary.
Distinct aphthce, attacks, as if by preference, children who do
not suck, and adults. The pustules are then always isolated,
less numerous, and occupy only the mouth ; the eruption pro-
ceeds, in most cases, without fever; however, it is sometimes
accompanied by febrile action, with gastric and intestinal dis-
turbance ; we regard it, ordinarily, in this case, as symptoms of
fever. This very mild disease is observed in all countries and
in all seasons. It is, however, much less frequent in France
than the stomatic, characterized by small psuedo-membranous
plates, which is daily taken for aphth®. Distinct aphthae pro-
ceeds through all its phases ia the space of a septennary, and,
although it may be sometimes accompanied by a kind of severe
local pain, it does not give place to serious affections.
PATEIOLOGY AND THERAPEUTICS. 209
Confluent aphthcB has a slow course, in opposition to distinct
aphthas, which has often lasted four or five days. It is rarely
confined to the mouth, for it extends, nearly always, to the
pharynx, and even to the intestinal canal. It attacks particu-
larly adults, but principally women in childbed, and it can as-
sume a very serious character. It commences, nearly always,
by chills, headaches, fever and vomitings. , These symptoms
calm, in most cases, after the eruption, the fever diminishes
continually, and it is even accompanied, sometimes, by parox-
ysms more or less decided. The fever appears again, not only
after the eruption, but is one of its symptoms ; whilst, on the
contrary, in ephemeral aphthaa, fever, when it exists, is either
accessary or simply concomitant, but is dependent upon another
cause than eruption.
In this second variety, the inflammation of the mouth is
much more intense and extended ; this cavity is hot, and cannot
bear the impression of the most mild liquid, as the pain is acute.
The disease takes often, in certain cases, a still more serious
character. Then there is difficulty of swallowing, on account of
the number of pustules, varying in size, which we observe upon
the veil of the palate, and in the back part of the mouth. Often
respiration is constrained, there is heat about the breast, hoarse-
ness of the voice, extreme dryness of the buccal mucous mem-
brane, upon which we see a number of small pustules, very simi-
lar to those which appear after the varioloid eruption ; in this latter
case, it is very common for it to occupy the interior of the mouth.
When the eruption extends to all these parts, and is very
confluent, as we have had occasion of observing, the patient is
tormented by pain in the praecordial, by anguish, by nausea,
and even by vomitings. If the eruption extends to the intesti-
nal canal, abdominal pain, diarrhosa, and often even of typhoid
symptoms, accompanied by other phenomena which we have
noticed, and then the disease may sometimes be prolonged to
the third week. When the disease is intense, the pustules soon
form a crust, similar to thickened and coagulated milk. The
volume of these crusts increases rapidly, and their color be-
comes yellowish or brown. Finally, it soon forms a scab, after
removing which, we perceive an ulcer of a reddish brown, from
27
210 ANATOMV, ORTHOPEDIA,
whence flows a fetid matter, and which, when it is extensive,
may cause gangrene, and, in a great number of cases, death.
Notwithstanding the numerous dissertations upon aphthee, it
has been difficult, even at the present time, to determine its true
causes. Authors have uttered, as it regards this, very simple
probabihties. We beUeve, however, to have observed that it
appears, most ordir\arily, under the influence of a humid tempe-
rature, and that it was most common in cold and marshy places ;
also, we have observed it more frequently in autumn than in
any other season, and most commonly in Denmark, in Holland
and in Zealand. But that which appears to be most certain is,
that it attacks, by preference, children and old men, individuals
of a lymphatic and debilitated constitution, those which are
subject to catarrhal affections ; finally, persons whose teeth are
decayed or incrusted with tartar.
It is worthy of observation, that the infraction of the laws of
hygiene, as habitual slovenliness, the use of bad aliments, such
as cheeses, salted meats, improper nourishment and care of
children, the use of badly prepared mercurial preparations, of too
hard aUments, unlooked for blows on the mouth, the result of
which is decayed or broken teeth, are as many causes capable of
giving rise to aphthae, or at least of favoring its development.
We have even seen this disease rage in an epidemic manner,
principally in hospitals destined for infants, and to attack, as if
by preference, those whose constitution was the most feeble or
most diseased.
As the dentist is so often consulted concerning the disease,
the history of which Ave are tracing, although, in many cases, it
extends to the organs which form his special domain, he ought
to know that the treatment which belongs to it is deduced prin-
cipally from the knowledge of the causes which produce it.
Thus, in discreet aphthas, it is necessary to withdraw the patient
from the morbid influence in the midst of which the eruption is
developed, in order that it may disappear of itself; softening
gargles, a little acidulated, emollient drinks are the only reme-
dies employed for adults ; the milk of a good nurse and clean-
liness are the best remedies for infants.
If, on the contrary, aphthee is confluent, it will be advisable
PATHOLOGY AND THERAPEUTICS. 211
to touch the diseased part with a small lancet, steeped in a fluid
sharpened by sulphuric or hydro-chloric acid. On the neck of
the patient we should apply warm cataplasms; we should give
him for drink, at first acidulated barley, afterwards a decoction
of quinquina. We should then seek to diminish the progress
of the disease by revulsives, as a blister on the neck or arms,
foot baths, sinapisms. If the swelling of the throat was such
that, as at the beginning, the respiration was constrained and
the swallowing difficult, it would be prudent to apply, about the
neck, but particularly beneath the mastoid apophysis, leeches,
the number of which should be proportioned to the age of the
person, or the intensity of the disease.
We should insist, in the second period, upon gargles made
with common water, the honey of roses, and a few drops of sul-
phuric acid. We should seek to calm the pain, by edulcorating
the drinks with the syrup of white poppy, or any other opiate;
we should follow the applications by tonic washes and gelatinous
baths. But it is sometimes prudent, in these cases, to lighten
his responsibility by seeking the advice of a physician, after
being well assured that the disease is not occasioned by caries,
or by the presence of any asperities that might be found neces-
sary to remove.
Phlegmasia or Abscess of the Gums, (Parulis.) — When the
inflammation of the gums has been carried to a certain point, it
is not rare that it terminates by suppuration. There is then
formed, in the tissue of the abscess, true phlegmasia, which we
designate under the name of parulis, and which, in certain cir-
cumstances, assume a very serious character.
These inflammatory tumors may be occasioned by decay of
the tooih or maxillary bones, by phlegmasia of the alveolar peri-
ostea, by irritation of the dental nerve, by contusions, compres-
sions, accumulation of tartar upon the gums, the presence of an
artificial piece in the mouth, and a bad plug; finally, they result
sometimes from that which we call a constitutional affection,
from rheumatism or from metastasis ; we meet with them, some-
times, without being able to assign any positive cause to them.
These abscesses, in general small and confined to the gum
itself, appear, by preference, in the neighborhood of decayed
212 ANATOMY, ORTHOPEDIA,
teeth, more commonly near the anterior and small molars than
the large ones, and oftener in the superior than in the inferior
jaw. Sometimes they constitute a pustule, and are developed
in twenty-four hours, and even in less time ; sometimes, on the
contrary, they form vast deposits, which affect the whole jaw on
the diseased side, and progress so slowly that they do not suppu-
rate at the expiration of a month, or six weeks, and even longer.
In the commencement of the gummy phlegmasia, the patient
experiences burning and a painful tension in the diseased part,
which, from a vermilion red, becomes livid in proportion as the
tumor increases in size ; soon there appears in the centre a
small white point, which opens of itself, if it is not opened, and
from whence flows a greater or less quantity of pus; as soon as
this liquid has escaped, the small opening closes, and the in-
flammation which affected a portion of the gum disappeared.
It often happens that this small abscess forms for itself an issue,
not very far distant from the suppuration, and it is necessary to
expel the pus. This kind of tumor seldom terminates by reso-
lution.
When a great portion of the gum is inflamed, the correspond-
ing jaw participates in the swelling; the heat is burning; and
extreme sensibility is now developed, which increases by touch-
ing it, or by the least movement of the jaw. Sometimes it in-
creases continually, the phlegmasia increases in violence, and
affects the whole economy ; from thence follows a general fever,
headaches, chills, inability to sleep, ptyalism, difficulty of open-
ing the mouth, and of talking; together with symptoms which
increase by degrees until the abscess opens ; this generally takes
place in the interior of the mouth, and is effected in eight or ten
days.
When the disease is not very intense, we confine our reme-
dies to topical emollients, small revulsive blood-lettings, or even
to applying one or two leeches upon the gum ; but we should
not forget that leeches increase sometimes congestion, by the
irritation of their pricks, and by favoring suppuration instead of
preventing it; furthermore, we should only apply them around
the inflamed tissue. We add to these different means, softening
gargles, and, in some cases, fomentations, with water slightly
PATHOLOGY AND THERAPEUTICS. 213
adulterated with spirituous liquor. We are sometimes so happy,
by these means, to obtain a complete resolution before the pus
has formed. But suppuration cannot be avoided ; it would be
irrational to confine ourselves to local remedies, for the treat-
ment of which, it is necessary, in following the directions of
Delamotte, to open the abscess, and make it too soon rather
than too late; by temporizing, we risk the suppuration extending
to neighboring parts, principally to the jaws ; and we are com-
pelled to believe that the pus opens for itself a route from with-
out, and causes a denudation of the bones, or of fistulas which
can with difficulty be cured.
If the abscess appears to follow this course, it is necessary to
open it largely, in the cavity of the mouth ; in other cases, a
simple incision would suffice. But, whatever may be the manner
of opening which we think proper to employ, the surgeon should
always incline the head of the patient forward, without which
he will swallow the pus, which is very disagreeable, and also
very injurious.
As to the best means for preventing the formation and return
of the abscesses of the gums, which depend upon the caries of
the teeth, it is necessary to extract the diseased tooth ; when
they depend upon the presence of the pivot of an artificial tooth,
it is prevented by its extraction, and principally by that of the
root which supports it; sometimes, from an abscess which is
opened into the mouth, a fistula remains in the gums, main-
tained as by the dental caries ; the extraction is nearly always
the only means of remedying it.
Suppuration of the Gums, ( Interalveolo- dental Pyorrhoea.) —
After having treated of the different phlegmasia of the gums,
and of their abscesses, it might appear scarcely physiological to
treat of their suppuration in another article. But when we have
defined that which we understand by suppuration of the gums,
the necessity of this arrangement will be perceived ; we do not
pretend, in effect, to speak here of this suppuration, which is
one of the results so common from inflammation having affected
the tissue of the gums : we now shall treat of phlegmasia. The
affection that we shall describe consists in a purulent dropping,
which results from a morbid secretion of the gummy alveolous
membrane.
214 ANATOMY, ORTHOPEDIA,
This disease has, for a long time, been confounded by authors
with scorbutica! diseases of the gums ; it is only in latter times
that its nature has been known and properly described. It
affects all periods of life, but particularly persons from thirty-
five to fifty years. It is common upon individuals who are
large and plethoric, who eat much ; it attacks both sexes,
although it appears to us to give the preference to women, espe-
cially at the time when their menses cease to appear.
Among the causes which may occasion this purulent flowing
of the gums, it is necessary to reckon habitual uncleanliness of
the mouth, the accumulation of tartar around the teeth, inhabit-
ing of unhealthy humid places, bad air, and, finally, all the
causes of general debilitation. In the next place, the mercurial
treatment, the suppression of artificial ulcers, hasmorrhoidal
fluxes, the repercussion of certain diseases of the skin, scrofu-
lous aff"ections, syphilis, etc.
The suppuration of the gum is eflected only by degrees.
Confined, at first, to certain teeth, it is not until after the expi-
ration of a certain length of time that it affects, one after the
other, all the rest. The incisor and the canines of the inferior
jaw are ordinarily the first attacked. Afterwards, it affects the
corresponding ones, and finally the molars. This affection
often presents, in its beginning, no appreciable symptom which
might reveal its existence. We could discover nothing by the
simple inspection of the gums, the patient did not even experi-
ence any pain. Only by pressing this membrane towards the
free edge, we may perceive, between it and the teeth, a certain
quantity of whitish matter, slightly glutinous.
If the disease is hereditary, or if it manifests itself in young
subjects, it announces by causing an indolent swelling of the
gums, which are soft, livid, fungous, and causes a dull sensa-
tion and a pain scarcely sensible ; afterwards, though the sup-
puration manifests itself, the teeth loosen and become painful to
the touch. Nevertheless, the teeth preserve their solidity whilst
the inflammation does not extend to any depth in their alveoli,
and the gums do not lose until late their normal color. The
patients complain only of a troublesome local feeling, and of a
dryness to which they give little attention. Then, as we have
PATHOLOGY AND THERAPEUTICS. 215
said, if, at this time, we press the superior gum from above
downwards, and the inferior ones from below upwards, we per-
ceive a white matter runs out, which is inodorous, not thick,
and which is soon reproduced.
One remarkable particularity is, that this fluid accumulates
at first only upon the external face of the gums ; it is only at a
more advanced stage of the disease that it has place equally
upon all points of this tissue which surrounds the necks of the
teeth. In the meantime, the disease making progress, those
teeth which until then had no cause of pain, acquire sensibility,
mobility and lengthen a little ; they become soft^ to use the ex-
pression which the patient employs to express the sensation
that he experiences, when the opposite teeth come in contact.
The purulent matter becomes more and more abundant; the
mouth exhales a fetid odor ; the gums, if they have not already
undergone any apparent change, tumefy around the neck of
the tooth, principally upon the external face, and are of a
violet red.
Whilst these symptoms manifest themselves upon the gums,
phenomena no less remarkable are taking place upon the roots.
Their external membrane furnishes, incessantly, a purulent
fluid, which escapes between them and the walls of their alveoli.
By degrees, this latter, yielding to this morbid influence, wears
away, and finally disappears, in proportion as the inflammatory
phenomena of the external membrane become more intense.
But, for the same reason that we have seen that the labial por-
tion of the gums is the first aflected, for the same also the ex-
ternal layer of the alveolus is the first absorbed. A contraction
of the gums results, the gums coming in contact with the roots
and abandoning the necks of the teeth. At times, the disease
arrives at this crisis, the teeth are late falling, and when this
happens, if we examine the surface of the roots, we will find
there something of a milkish white, and scattered with purulent
striae.
Such is the course of this disease. We do not know pre-
cisely its duration ; for it extends, in certain instances, to the
entire loss of the teeth, that it takes six, ten, and even fifteen
years to destroy. It has, nevertheless, a rapid progress, and it
216 ANATOMY, ORTHOPEDIA,
is not rare that it suddenly ceases to progress, and even that the
purulent dropping, which takes place under the gums, ceases
without any aid of art ; the teeth continue to be movable and
elongated ; but tliis is often only many years after the disease
commences.
As most of the local affections that we have spoken of disap-
pear after the extraction of the tooth around which the dropping
takes place, we naturally regard the teeth as the first cause of
all these disorders. Fauchard and Jourdain have at least estab-
lished the conclusion, that the disease may be regarded as
purely local : according to them, all the affections that we have
described are only the inevitable result of the development of
the efforts that nature makes in order to cause the expulsion of
organs that it has affected even in their vitality.
If this reasoning is sometimes conformed to the truth, yet we
cannot deny that, in the greatest number of cases at least, this
disease affects not the general constitution of the subject, but
principally the changes which follow in the exercise of different
functions at certain ages of life. According to some authors,
the dropping of the purulent matter ought principally to be re-
garded as a salutary secretion, capable of preventing the devel-
opment or suspending the course of serious affections ; this
seems to be the most probable opinion.
Bourdet, who considers this affection as purely local, pro-
poses, in order to remove it, to destroy the ulceration, at a point
beyond the suppuration, with a flat and small cautery, strongly
heated, that he places as far as possible between the gum and
root, even to the depth of the space resulting from the destruc-
tion of the alveolar ridge, having care to burn, two or three
times, the whole internal face of the gum. If, eight or ten days
after, we press the edge of the gums, and there still flows a little
matter firom it, we cauterize, according to him, a second or third
time. Finally, when, in spite of these cauterizations, the flow-
ing continues, he advises to destroy, with the scissors, by two
incisions, which unite to the right angle of the side of the point
of the root, all the part of the gum deprived of its alveolus.
Toyrac, who doubtless had never read Bourdet, proposes exactly
the same means as he gives, as the result of his own experience.
PATHOLOGY AND THERAPEUTICS. 217
Cauterization is, unfortunately, far from being as constantly-
followed by success as Bourdet believes. Jourdain, who has
had occasion of seeing equally as many persons affected with
this disease, asserts that he has never cured a si?igle person by
the use of this means. Let us admit, then, although it will not
be a fact altogether demonstrated, that this purulent state of the
gums is the result of dental caries, or a change of the alveolar
partitions, we might be liable to see all local treatment fail, at
least if the disease is recent, and the subject does not enjoy good
health.
To change the general constitution the efforts of art should
aim ; it possesses, in this respect, means whose general thera-
peutical action might produce advantageous results. IjCt us
take notice, at the same time, that if the suppuration is abun-
dant, and when it exists many years, it is always advantageous,
in the course of general treatment, to establish an artificial
ulcer, and to prescribe the use of purgatives, at intervals suffi-
ciently near to avoid the brisk succession of the flowing of the
purulent matter.
Dental Fistulcs. — As we have already seen that decayed teeth
decay often at their roots. A suppuration results from it, in the
alveolus, always accompanied by a painful swelling in the gums.
Here, as Fox justly remarks, the laws which determine the
flowing of pus are the same as those which we observe in ab-
scesses in general. The suppuration is established in some part
of the surface of the root, and forms an opening in the place
most favorable to its flowing. The periosteum whicli covers the
root where the deposit is formed, tumefies, and sometimes at-
taches itself. The pus collects, then, as in a sack, which, in
swelling, produces a considerable pressure upon the walls of the
alveolus, whose anterior edges are partly absorbed before those
which are found within the mouth. The progress of ulceration
continues until the gum itself becomes pierced through that part
which corresponds to the extremity of the root, and the flowino-
of pus made by this opening, whose edges generally swell, has
the appearance of a small red fungus. Sometimes, after the
discharge of pus, the inflammation ceases ; but the ulcer rarely
closes, and a small crooked opening remains, which constitutes
what we call a dental Jistule.
28
218 ANATOMY, ORTHOPEDIA,
Some authors confound this affection with the fistulous ul-
cers of the gums, Maury places himself amongst these, by say-
ing, that it often happens that, after the opening of the abscesses
of the gums, not having been brought under the influence of
the remedy, in spite of the general means employed, forms the
general fistules of moderns. In that, both commit an error ;
for fistulous ulcers of the gums diff'er from dental fistules in
this, that the first are only openings of the abscesses belonging
to the gums, whatever may be the cause that prevents it from
closing, whilst the second have their first cause in the alveolus,
and affect but passively that part of the gum by which they are
surrounded.
The dental fistules are then generally occasioned by the de-
cay of a tooth or maxillary bone, or even by the parts of a tooth
or alveolus, which, not having been affected by the suppuration
are situated under the gums or engaged in their tissue. Some-
times, the ulcer presents only a small orifice, often obstructed
by the presence of a watery ichor, which flows from it, and dries
when it comes in contact with the eye. Sometimes we perceive
two or three of these openings instead of one, and they are
generally near each other. A stylet introduced into one of
them, we perceive that the bone is denuded and movable, or
that the diseased tooth is insensible but vacillating. That
which we have said of the causes and formation of dental fis-
tules, prevents us from saying much on their treatment; it is
always necessary to extract a portion of the decayed tooth which
injures it, or to attempt, by employing the best means, the ex-
foliation of the affected bone, if it is the alveolus which is dis-
eased. This is not only applicable to the case where the fistula
opens in the mouth, but it is the only one which should serve
as a guide when it extends across the thickness of the jaw or
above the cheek bone, if the cause of the abscess is in the supe-
rior jaw; or near the angle of the inferior jaw, or the edge of its
base, if the cause of the disease is in the inferior jaw.
These dental fistules, aff'ecting the face, are also very com-
mon ; we have seen many persons, amongst others our friend
Dr. G., aff'ected with one a long time, and waited in vain for
many years, in the hopes that it would cure of itself. Near the
PATHOLOGY AND THERAPEUTICS, 219
issue by which the separation was affected, the skin was
wrinkled, and had a spongy appearance ; its tissue was red and
soft. After the extraction of the tooth, the flowing of the pus
diminishes gradually ; the exterior opening closes ; but, as the
ulceration has destroyed a part of the cellular interstices and
teguments, the skin contracts and heals, and, in the place occu-
pied by the fistulous ulcer, a hollow or deep cicatrix, which we
sometimes suppose as the result of a scrofulous affection ; a de-
fect which should be remedied by the application of appropriate
means, and which we render always less irregular, by accele-
rating, as soon as the abscess forms, the flowing of pus, by an
incision made with the point of a lancet.
As the three affections which we have described under the
name of abscesses, of suppuration of the gums, and of dental
Jistules, have characters common with the purulous or mucous
collections of the maxillary sinus or antrum of highmoria, and
that, on the other hand, the treatment of these collections,
although belonging to general surgery, demands, very often, the
intervention of the dentist, we believe a separate article should
be devoted to it.
Abscess and Dropsy of the Maxillary Sinus.
The maxillary sinuses, of which we have designedly given a
very brief description in our anatomical part, as it has but an
indirect connection with our subject, are, as we know, two large
triangular hollow cavities, in the thickness of the maxillary
bone, immediately beyond the orbital fossas, and without the
nasal fossas, agreeing to that part of the face which forms the
jaw. Lined by the mucous membrane, which is the continua-
tion of that which covers the surface of the mouth and the nasal
fossae ; these cavities are susceptible of being filled with a true
pus or a simple mucous substance ; hence their abscesses, and
that which we commonly name their dropsies.
The purulent matter which forms the abscesses of which the
maxillary sinus may be the seat, is as often the direct product
of a termination by a suppuration of the inflammation of the
mucous membrane which lines them ; but this inflammation
220 ANATOMY, ORTHOPEDIA,
is not, most ordinarily, the cause of this abscess ; they are more
frequently occasioned by decayed teeth, which affect their
alveoli and the walls of the maxillary sinus, by abscess of the
gums, that we have described under the name of parulis, hy a
tubercle which developes itself, as Boyer very judiciously re-
marks, at the roots of the teeth which correspond to the sinus ;
finally,as Vidal, (of Cassis,) remarks, by an ulceration of osseous
tissue itself, whose suppuration communicates with the cavity
of the sinus and fills it.
Whatever may be the source from whence the purulent mat-
ter proceeds, the first indication of its accumulation in the max-
illary sinus, is a dull, deep pain, which affects the jaw, and
even extends from the molar teeth to the orbit. The teguments
of the face near the painful spot, are not at first tumefied,
do not, consequently, change their color, and it can be com-
pressed without hurting the patient. Yet, in proportion as the
purulent matter collects, the jaw swells; the walls of the sinus
extends, and forms an exterior tumor above the last molars and
interior side of the palate ; the bone softens and yields under
the pressure of the finger ; the fluctuation becomes sensible ;
the deformity produced by the dilation of the sinus is very ap-
parent ; a yellowish, purulent matter comes from the nostrils
when the patient blows his nose, or makes a strong expiration.
This liquid accumulates, having no free passage by a natural
opening of the sinus,* which is too compressed and elevated or
close, it softens, by its remaining and its change, the inferior
walls of this cavity are destroyed by degrees ; and , finally, one or
more issues by the nostrils, alveolar arch, and in different parts of
the face are formed, from whence fistules result, which tend to a
common centre, which is the cavity of the sinus. The patient
is then slightly relieved by the discharge of pus; the jaw, at
first tumefied, sinks, but the fistules, formed on the side of the
*This opening, situated superiorly and anteriorly on the side of the nose,
between the two cornets, nevertheless nearer the superior, did not much
exceed the diameter of a pigeon feather; its form is little obiongated, and,
upon many subjects, pituitary membrane forms on the side of the sinus a
kind of fold, which gives to it an oblique direction, consequently, it is
sometimes difficult to be perceived.
PATHOLOGY AND THERAPETiTICS.
221
the alveoli, of the jaw, beneath the orbit, and in the nose, con-
tinue; the molar teeth are loosened, the bones are carious, and
the mouth exhales an insufferably offensive odor.
As it regards the singular mucous matter which fills the max-
illary sinus, and which constitutes what we call dropsy of this
cavity ; it proceeds simply from irritation of its lining mem-
brane ; an irritation which is not sufficiently great to cause
inflammation, and, consequently, an accumulation of purulent
matter, but which is sufficient to induce a more abundant secre-
tion of mucous fluid which it constantly secretes. The only
sign which distinguishes this mucous secretion from purulent
collections is, that they never proceed from inflammatory symp-
toms, which always attend the development of the latter, and
that they more frequently affect young subjects, since, of three
cases which Boyer describes, the oldest was not twenty years,
and the most remarkable case on record, and of which Dubois
has given the details to the Professors of the School of the An-
cient Society, and upon the disease had commenced at the age
of seven years and some months. As this case sums up, at
once, both the diagnostic and therapeutic indications of this
disease, we shall here give a detailed description of it.
A child of seven years had a small hard tumor, as large as a
walnut, at the base of the apophysis rising from the superior
maxillary bone of the left side, neither growing nor producing
pain. The parents paid no attention to it then ; but when the
child had reached his sixteenth year, the tumor commenced to
grow and become painful. Before he had arrived to his eigh-
teenth year, the tumor had acquired such volume that it cover-
ed the edge of the orbit. The eye was forced backwards, the
eyelids were closed ; the roof of the palate towards the mouth
was projected out, the corresponding nostril was stopped up;
towards the jaw was a considerable tumor, whilst the nose was
forced back from the opposite side ; finally, the skin which,
from the beginning of the tumor, continued with the inferior
eyelid, was tender and red, and threatened to be broken ; the
upper lip was drawn upwards, thus permitting us to see the
gums, which were much more prominent than those of the op-
posite side, and it was only from this point that we were able to
222 ANATOMY, ORTFIOPEDIA,
see the diminished size of the bony walls of the sinus. The
patient spoke, chewed and swallowed only with difficulty.
Pelletan, Sabatier, Boyer and Dubois, agreeing upon this sub-
ject, thought that a fungus of the maxillary sinus existed, which
ought to be removed. Dubois, preparing to make the operation,
perceived that there was a manifest fluctuation to the level of
the gums ; this circumstance caused him to abandon the idea
of a fungus, but he expected, before deciding, by making a slight
opening, that the flowing of a viscous liquid would reveal to
them the true nature of the disease. He then made an incision
upon the alveolar bone, from whence soon flowed a liquid
which resembled that which flows from the grenouilletee. He
then introduced into the opening a probe, by the aid of which
he perceived that the cavity had a great analogy to the anterior
volume of the tumor; and by directing the probe with discre-
tion, in order to assure himself that there was no fungus there,
he perceived a hard body, which appeared to be an incisor tooth,
and was very near the opening.
Five days after the operation, Dubois extracted the two inci-
sors and a molar, and elevated, at the same time, a correspond-
ing portion of the maxillary bone. As he caused an abundant
haemorrhage, he was obliged to fill the wound with lint ; but it
ceased some days after, and Dubois was able to examine, with
ease, the interior of the cavity; he saw, on the superior portion,
a white spot, which he supposed, at first, to be pus ; but upon
touching it with a probe, he saw that it was a tooth, which he
extracted.
The remaining portion of the treatment consisted merely in
making injections, and in applying the ordinary preparations.
At the expiration of six weeks the cavity disappeared ; but the
tumefaction of the jaw, palate, and the displacement of the nose
remained. Nevertheless, after a year and a half, no kind of
trace of it remained ; the patient had been entirely cured.
But, although matter, either purulent or simply mucous, had
accidentally accumulated in the maxillary sinus; in a word,
although there was an abscess or dropsy there, the essential point
to accomplish was, to free the cavity of its contents. Jourdain
has proposed, in order to accomplish this, to introduce into the
PATHOLOGY AND THERAPEUTICS.
223
natural opening detersive injections, by means of a crooked
tube introduced through the nostrils ; but reason and experience
have demonstrated that this operation, a true catheterism, was
infinitely more difficult and much less efficacious than we
might think ; consequently it was abandoned. It is, at the
present day, received and adopted in principle, although it can-
not cure an abscess or dropsy of the maxillary sinus, or destroy
the decay and fistules which are the consequence ; yet we can
employ, in order to form an artificial opening, for the flowing
of the accumulated matter.
Many methods have been prescribed for the accomplishment
of this ; but that which is preferable to all, and which we give
Meibonius the credit for, although it was employed by other
practitioners after him, is that which consists in extracting the
superior molar teeth upon the diseased side, then to perforate the
alveolus, and to penetrate the cavity as far as the sinus, in order
to clean it, so that we can make, by this artificial opening, de-
tersive injections.
As a general rule, we should always prefer to extract those
molar teeth which are decayed, loose, yellowish or painful,
whether they may or may not be the cause of the disease. If
many are decayed, we should extract them; and, in this case,
there is ordinarily a decay of the alveolus and fistule of the
gum ; that which renders the disease very apparent, and the ex-
traction of all the decayed teeth absolutely necessary. When
all are healthy, we should always prefer to extract the first or
second large molar, not only because they are more easily dis-
pensed with than the anterior teeth, but because they corres-
pond to the middle part of the declivity of the sinus.
Bayer recommends the isolation of the neighboring parts, by
four incisions forming a square, the gums covering the portion
of the alveolar border should be penetrated, in order that they,
being deprived of all communication with the rest of the gums,
may be elevated without causing the patient to suffer. This
precaution seems to us to be only useful in the case where the
former loss of the teeth, towards the point where we wish to
perforate, has already permitted the alveoli to unite, and the
gums to cover them.
224 ANATOMY, ORTHOPEDIA,
As it regards the perforation of the alveolus, different methods
have been recommended ; some practitioners employ a simple
stylet, Desault employs a perforating trepan, Richter a trocar.
When we have been called upon to perform this operation, we
employ, with great success, a triangular, pointed and sharp in-
strument, as the trocar, mounted upon a round handle. We
use this instrument in perforating the deepest roots, by turning
it between the fingers, in order to penetrate the root. When
the resistance ceases and the flowing of matter commences, the
end is accomplished. As we are compelled to commence the
opening at a certain time, in order that it may be sufficiently
large, we advise it to be filled with a plug of wood, in order that
we may empty the sinus in time, or with a tube. The first
method is preferable, because it prevents particles of food and
air from entering it.
This method of emptying the maxillary sinus is, doubdess,
the most sure and reasonable, and, fortunately, that which is
most frequently employed. But the disease does not always take
the course we have mentioned : "The humor may be of different
consistency; it may be in a different part of the cavity, or be shut
up between its walls; and besides, it does not form a scarcely
considerable collection in a cavity, without the disposition of the
parts is modified ; the declining point may vary. It is this fact
which explains the success obtained by different proceedings,
and gives a real importance to each one of them."
Lamorier opens the sinus between the zygomatic apophysis
and the third molar tooth. Desault accomplishes it by the
fossal canine ; upon this side, the wall is thinner, easier of ac-
cess, and the undertaking less difficult ; it is necessary only to
remark, that if we see proper to employ the procedure, wd must
be careful to operate, as before, by an incision made in the jaw,
but simply to raise from above the labial angle, in order to dis-
cover the gum, to make an incision of a centimetre or two in
length, in such a manner as to denude the bone before perfo-
rating it; afterwards we place a band of linen in the opening.
If a tumor arises in the side of the mouth, and particularly if
it fluctuates towards the roof of the palate, we should, according
to the advice of modern surgeons, imitate Cheseldon, who per-
PATHOLOGY AND THERAPEUTICS. 225
forates the sinus from this side. If there should already be a
fistulous opening here, it may only be necessary to enlarge it,
as is demonstrated by the following case :
In 1841, a youth, aged sixteen, named J. An. Fuillant, by
trade a locksmith, entered the charity hospital under the direc-
tion of M. Gerdy, (Saint-Jean Rail, No. 13.) He had, upon the
anterior wall of the first bicuspis, a fistula, from which flowed
a large quantity of pus. M. Gerdy, having convinced himself
that this came from the maxillary sinus, enlarged the fistula
already existing, so as to encroach upon the anterior and inter-
nal walls of the sinus. As the result of this perforation, the
canine tooth became loose, but by degrees it recovered as much
stability as the teeth on the other side. The opening made into
the sinus was large enough to admit a roll of cotton as large as
the little finger. The progressive development of the sinus had
caused the inward deviation of the four superior incisors and
the left canine tooth, which had this movement.
Finally, when pus flows from the jaw and the orbit, it is easy
to perceive that the fistula through which it discharged cannot
be healed, except by perforating the alveolar border at the most
dependant part. All operations, therefore, upon the fistula is
useless, the cause being inflammation of the sinus, accumula-
tion of matter in it, suppuration, with or without caries or ne-
crosis. The treatment of these superior fistulas is the same as
that of urinary fistules ; to wit : to change the course of the fluid
from the opening through which it has been accidentally dis-
charged. Then some emollient applications will promptly ob-
literate the fistula. We shall not here speak of the treatment of
the disease of the sinus, nor of caries and necrosis of its walls.
That which belongs to our immediate speciality, is the opening
of the sinus ; for if this disease is induced, for example, by the
presence of a foreign body, the development of a polypus, the
presence of worms, as we have seen, the cure depends upon the
removal of the one, and the destruction of the other.
29
226 ANATOMY, ORTHOPEDIA,
Adhesion of the Gums to the Jaivs and Lips.
Whatever may be the nature of the inflammation of which the
gums are the seat, whether direct or consecutive, that is to say,
belonging to their tissue or dependant upon changes of the os-
seous parts which they cover, it causes a sweUing, that unites
them to the walls of the mouth, in such a manner as to occasion,
under certain circumstances, an adhesion between them and the
jaws. This adhesion, which we have said might sometimes re-
sult from a congenital vice, generally begins at the moment
when the inflammation of the gums terminates in suppuration,
or rather, when this last assumes the character of an ulcer.
Sometimes it is partial, sometimes it occupies the whole extent
of the internal side of the gum, and sometimes both sides at the
same time.
When the causes of this adhesion present themselves, no
means should be neglected in order to remove them ; for, what-
ever may be its extent, it always interrupts the functions of the
mouth. We nearly always succeed in preventing it in persons
affected with maxillary Auctions, by mucilaginous gargles, and
by frequently passing between the jaws and the gums some
analogous liquid, as a decoction of the root of althcB, etc.
If, for want of precautions, or in spite of precautions, we can-
not prevent the adherence, it is necessary to take advantage, in
order to destroy it. At the time when it appears, a finger may
suffice to prevent it ; but if it is of long standing, it will be
necessary to have recourse to the bistoury. The separation
being made, we should seek to keep the parts separated, in such
a manner that it would be entirely impossible to unite them.
In order to accomplish this, we should place in the wound a
piece of cotton or of lint, steeped, as we have already said, in
some mucilaginous liquid.
Finally, if the adherence is complicated of a fistula border-
ing upon the exterior, but proceeding from a dental or alveolar
caries, in order to treat this affection the adherence must be de-
stroyed ; the extraction of the teeth should not take place till
afterwards ; otherwise, this operation might occasion a tearing of
the jaw, which follows a sharp pain or an inquiet hoemorrhage.
PATHOLOGY AND THERAPEUTICS. 227
This was the case with Dr. G , of whom we have spoken
whilst treating of dental fistula.
If the jaws may, in consequence of some inflammation, con-
tract an adherence with the gums, they may, for the same rea-
son, contract one with the lips; only this adherence is more
rare, because the excessive mobility of the lips opposes it much
more than the jaws, and these latter, being thicker, and better
provided with cellular and vascular tissue, are in a more favora-
ble condition to unite, under some circumstances, with the
parts with which they come in contact.
Whatever may be the cause of this adherence, it is certain
that it is sometimes the result of an operation in the mouth, as
the extraction of a tooth when the lips were inflamed ; but it is
seen oftener among persons whose lips and corresponding gums
are the seat of an ulcerous affection, for example, and princi-
pally of syphilitic ulcers. A burn may, without doubt, occa-
sion it.
' The most curious example that we have met with of this ad-
herence, is that of a young man, of eighteen years of age, who
had his upper lip united to the gum surrounding the four inci-
sors, in consequence of a venereal ulcer. This adherence was
such, that the lip was retracted, and formed, below the lip, a
thick loop, which allowed us to perceive the six anterior teeth,
which had commenced to jut out very disagreeably. All
that was required was to cut this loop, in order that the lip
might be depressed, and the teeth return, according to the phy-
siological law that we have established, (in another part of the
work,) to the vertical line to which they belong. Our conduct,
in this instance, marks out the course to be pursued in similar
occurrences.
As to the union of the lips, it may be complete or incomplete :
the first, as congenital defect of conformation seems so rare,
although Berad speaks of it, that Boyer himself makes no men-
tion of it; and as to consecutive accidents, we know of but one
instance, that is related by Turner, of a miller, who having had
his lips excoriated, they united together, in such a manner, that
a slight opening, which permitted him to have his food intro-
duced through a tube, finally disappeared, and he died of hun-
228 ANATOMY, ORTHOPEDTA,
ger. In all such circumstances, the rational indication is so
easy to be established, that it suffices to mention it ; it is the
division of the cicatrix.
Constitutional Affections of the Gums.
The diseases of the gums that we have described heretofore,
have, as a common characteristic, a nature primitively inflam-
matory, and generally dependant upon a local cause. But
these are not the only ones to which they are subject ; they
may, besides, take an active part in certain affections which
attack their entire constitution, and offer, in this case, symp-
toms, of which the study belongs, before all, to general patholo-
gy, since it yields only to the treatment of constitutional affec-
tions ; but the dentist ought to know perfectly well, if only to
distinguish them from local diseases, and not to apply any treat-
ment without the rules of general therapeutics.
The essential affections of the gums may be divided into
scorbutic, scrofulous, syphilitic or mercurial nature. We will
examine, successively, all four in a summary manner.
Scorbutic Affections of the Gums. — In the actual state of
science, it is difficult to give an idea of the intimate nature of
scurvy. This disease consists, as the adepts of the physiological
school have lately maintained, in a chronic irritation of the san-
guinous capillaries ; the solidists, of the school of Pinel, think it
is owing to the atonity of the red vessels ; and the humorists, who
are our partisans, believe it is owing to a defect of the blood ;
still, it is no less true, that the gums are nearly always affected
first.
The changes which these parts experience, from the simple
tumefaction and bleeding, even to their complete disorganiza-
tion, are infinite. The patient at first experiences a disagreea-
ble sensation, a kind of unpleasant itching. Soon the gums
become swollen, take a red color, and bleed from the slightest
touch. They remain sometimes in this state ; but, most ordi-
narily, the disease progresses ; then, from being tumefied, they
become fungous, of a hvid red, and exhale a fetid odor; soon,
they acquire a considerable size, are the seat of a deep ulcera-
tion, which, in certain cases, envelopes the dental arch.
PATHOLOGY AND THERAPEUTtCS. 229
At this Stage of the disease, liEemorrhoges are very frequent,
the teeth become loosened in their sockets, and finally drop out.
It is rare that their color is not much changed ; this becomes
blackish or brownish. From the gum, the disease not only
affects the teeth, but even causes a caries of the maxillary bone,
which is sometimes very great. In consequence of this disor-
ganization, the dental nerve is liable to be exposed, and this
circumstance may become the cause of violent pain.
The gums sometimes take a color so deep that we believe
them affected with gangrene. At other times, they become
covered with fungous excrescences, which often acquire an
enormous size. These excrescences vary in color, form and
consistency. Sometimes they are of a livid red, and represent
tubercles with a large base, or a straight pendant, but of a firm
texture ; sometimes, on the contrary, they are of an ash-grey,
resembling tattered rags, and' are flabby and bloody ; this is
their habitual character.
It is difficult to confound scorbutic afiections of the gums
with any other changes that we have described. But all symp-
toms disappear, when, to local symptoms are added pathogno-
mic signs of the disease, which are vague pains in the limbs,
and a spontaneous lassitude, and an habitual sadness, a swollen
face, particularly of the inferior eyelids, a general tumefaction
of the skin, and the appearance upon the limbs, of a purple,
bluish or vivid red color, sometimes yellowish at their circum-
ference.
In order to remedy scorbutic changes of the gums, we
should not pursue any chimerical action. It is only upon the
use of proper means that we can relieve the economy from this
state of general debilitation, a true anasmia into which it is so
often plunged — means, at the head of which we find the power-
ful resources of hygiene, which should be the basis of all rational
treatment. Nevertheless, from the time when the gums are tu-
mefied, spongy, or when the teeth commence to vacillate, but
before any ulcers exist, we should endeavor to arrest the pro-
gress of disorganization, by the frequent use of gargles, acidified
with the sulphate of alumine or sulphuric acid, the first in doses
of one drachm, with a quart of a decoction of barley and red roses
230
ANATOMY, ORTHOPEDIA.
the second with one-half drachm only with two quarts. These
tonic astringents are applicable when the bleeding is considera-
ble. We have also prescribed spoon-wort as a specific in this
case.
But if the gums are already ulcerated, we may use, with ad-
vantage, gargles made with barley water, honey of roses, and
hydro-chloric acid, in this proportion: acid, one and a half
drachms ; honey, one ounce ; the decoction, one pint. The
excrescences themselves often disappear under the influence of
this treatment ; but, if they do not, the bistoury must be resort-
ed to. Finally, in the odontalgic case resulting from the denu-
dation of the dental nerve, it would be advisable to fill the
cavity of the diseased tooth with cotton, moistened with a nar-
cotic tincture. This precaution should be observed, as we
might not be able to plug the tooth without aggravating the
pain, or extract it without running the risk of a haemorrhage
difficult to stop, and always more dangerous as the subject is
more weak.
Scrofulous Affections of the Gums. — When we examine the
gums of scrofulous individuals, we find that they are generally
pale and soft, sometimes even swollen, and covered with ulcers.
These ulcers issue a semi-purulent, whitish, nauseating matter,
and often loosen the teeth, which they separate from the gums,
and finally cause them to drop out. This state might be as
well confounded with the disease which we have described un-
der the name of suppuration of the gums, if the discoloration
and continual swelling of the skin, the constant issues, the
choking of the sub-maxillary, lymphatic and abdominal gan-
glions, the inflation of the belly, the tumefaction of the articular
tissue, did not denote its true character.
When it is plain that this morbid state of the gums proceeds
from scrofulous cachexy, the only means that can remove it is,
to apply the treatment belonging to this cachexy ; we can only
aid it by the use of lotions, gargles made with a decoction of
red roses and of bark of oak, of quinine, or of simple water
mixed with some spirituous liquor. We have also prescribed
lotions with liquids containing the iodurated potassium, com-
mended lately as a powerful anti-scrofulous.
PATHOLOGY AND THERAPEUTICS. 231
But we should always be very cautious in the administration
of such powerful substances; it would be better to the means
that we have enumerated, and to which we might add frictions
made upon the gums, with powders formed of a mixture of
magnesia and sulphate of quinine, or of any other tonic astrin-
gent substance. It is almost useless to say that it is indispen-
sable to prescribe the use of succulent animal nourishment, of
wines generally, the inhabiting of dry and well aired places,
exercise and insolation.
Syphilitic Affections of the Gums. — The symptoms of the ve-
nereal disease which appear upon the gums, are ordinarily of
an ulcerous nature. These ulcerations, for the same reason
which all have that appear upon the gums, are not as easily dis-
tinguished as it is commonly said and generally believed.
Nevertheless, their pointed shape, their greyish bases, and their
tendency nearly always to enlarge, are indications which point
out their true character, and which can easily prevent us from
confounding them with aphtha or any similar affection of which
we have heretofore spoken.
The treatment of these ulcers does not differ from that which
belongs to the other symptoms of which it is the consequence.
However, if they were first and very recent, we can not only arrest
them at once, but even cure them altogether, by touching them
lightly, as far as a perfect cicatrization, with a pencil of nitrate
of silver, (infernal stone,) experience having proven to Ricord,*
Ratier and Desruelles, that syphilis soon becomes constitution-
al, that is to say, inveterate, as we have believed.
Mercurial Affections of the Gums^ (Mercurial Stomatitis.) —
Persons who have used mercury as an internal or external
medicine, men employed in mines of this metal, or those who
by profession, habitually employ it, as the workmen in glass
manufactories and gilders, are exposed to a particular kind of
disease, which at first affects the gums.
The result of this disease are more or less deep excoriations.
When, then, they are about to form, the gums are at first very
hot, then they become engorged, and are of a smooth white, de-
* RicoRD ; Practical Treatise upon Venereal Disease.
232 ANATOMY, ORTHOPEDIA,
pressed around the crowns of the teeth, and the rest of the gum
assumes a violet color. We sometimes observe, upon the gum,
mucous projections, a kind of cicatrix. All these parts are
very painful when subjected to the slightest impression.
The inward part of the throat is, moreover, red and phlogistic,
the sub-maxillary ganglions are engorged; the patient expe-
riences great difficulty in swallowing, talking and spitting ; the
slightest movement of the jaws causes violent pain; finally, a
thick and ropy saliva flows in abundance from the mouth, and
unlooked for gripings take place, which are only the preludes to
an intense diarrhoea.
Soon, a kind of small pustules manifest themselves, which are
converted into abscesses, and leave, near their gaps, ulcers,
which extend as much more in size and in depth, as their cica-
trization was of long or short continuance, that is to say, as the
cause which produced them was greater and of longer duration.
They differ from aphthaj in this respect, the latter are more su-
perficial, and of a white color. They are also, in general, more
numerous than those which result from syphilitic virus, and are
not, as those, cut off at the top, although their bases are as grey,
and sometimes even bloody, as scorbutic ulcers.
In this affection, the congestion of the gums is, in general,
proportioned to the quantity of mercury which is found absorb-
ed in it. If this quantity is considerable, the ulcers are very
numerous ; often they are not even confined to the gums, for
they occupy, as frequently, the sides of the tongue and the whole
extent of the mucous membrane which lines the mouth. The
teeth then become blackish and loosened, and the breath ac-
quires an insupportable odor.
The circumspection with which we daily administer mercury
in France, has much diminished the frequency and intensity
of the accidents which result from its employment ; and the
general adoption, in the work-shops where the metal is employ-
ed, of certain precautions of which we have spoken in the chap-
ter on hygiene, has preserved the workmen from many accidents.*
*It would be desirable that the new mode of gilding should generally be
adopted, that is, by the means of galvanism, which excludes the use of
mercury: the health of the workmen would be thereby much improved.
PATHOLOGY AND THERAPEUTICS. 233
But when these accidents do occur, it is necessary to withdraw
the workmen from its action, and to keep the patient from its
employment. We then prescribe softening gargles, made with
barley, the roots of althae, flaxseed, honied milk, slightly
adulterated with the syrup of white poppy. If the salivation is
too abundant, we should seek to restrain it, by applying cold
bodies, but principally by compresses, steeped in vinegar
water, upon the jaws and the corresponding regions of the
salivary glands.
But, of all the means, that which experience demonstrates to
be the most efficacious, consists in frictions, repeated frequently
during the day, with the powder of muriate of dry chalk, and
gargles rendered astringent and tonic by the syrup of caechu,
and even the alcoholic tincture of ratanhia, or any aromatic
spirituous liquor ; seconded, finally, by foot-baths, and revulsive
purgatives, if the inflammation has not gained the intestinal
tube, and if there is no diarrhoea.
An honorable professor of the faculty, Chomel, believes vapor
baths an efficacious remedy for mercurial stomatitis. He was
led to the use of this means by the following circumstance, which
he thus relates :*
"After being about twenty-five years physician to the Charity ^
we received into our service a poor woman, covered with erup-
tions ; we prescribed the use of mercurial frictions, in consequence
of which she experienced all the ill eff"ects which habitually result
from the use of mercury. We then ordered a vapor bath, (not
expecting to obtain the result for which the frictions were in-
tended ;) the buccal aff"ection disappeared as by enchantment.
The success of this attempt gave us some hopes upon the effi-
cacy of this means ; we have employed them many times in
similar instances ; but, although it has often contributed effica-
ciously to the cure of the patient, it has not, in every case, an-
swered our purpose."
This able practitioner has, very recently, however, employed,
very advantageously, vapor baths upon a female admitted in his
service, at the Hotel Dieu, for mercurial stomatitis, proceeding
*GazeUe of the Hospitals.
30
234 ANATOMY, ORTHOPEDIA,
from working in gilding brass, and with whom a violent diar-
rhoea contra-indicated, evidently, the use of purgatives. This
patient had symptoms of the affection carried to the highest de-
gree; she nevertheless departed from the hospital perfectly cured,
after only seventeen days of treatment. We then recommend
to practitioners vapor baths, if not at the commencement of the
disease, at least at the time when the dryness of the skin an-
nounces that it is tending to the intestinal tube. We have recom-
mended them, not long since, with much success, to a young
commission merchant, who, in order to free himself from a syphi-
litic affection, had irrationally used mercurial frictions, and
with whom, to the worst of the preceding enumerated symptoms,
was added a trembling of the limbs.
Gangrene and Sphacelus of the Gums.
Most of the authors who have written upon the diseases of
the mouth, have treated of gangrene and of the sphacelas of the
gums in a distinct part. But the actual state of pathology,
principally anatomical pathology, does not permit, according to
our opinion, to make this distinction ; gangrene being, to speak
correctly, excepting in cases when it proceeds from the action
of a violent compression, only one of the modes of the termina-
tion of the inflammatory diseases that we have described, car-
ried to the highest degree of intensity ; and sphacelus, ihe result
of one of the constitutional affections of which we shall treat,
and whose effects will be particularly centred upon the gums.
Whatever may be the cause of the two affections in contem-
plation, independent of the commemorative signs which be-
long to each one of them, the first is recognized by the bluish
color, which soon becomes slaty and even black, in many points
of the gum, accompanied with a horrible odor; the second, by
a kind of decomposition of these parts, which become soft, livid
and are reduced to a kind of putrefaction, and abandon the
alveolar borders, without, however, being accompanied with an
odor as unpleasant as the first, for it is more insipid and nau-
seous than fetid.
These two states, opposed by all the proper means for favor-
Pathology and therapeutics. 235
ing the termination of the different ulcerations of the gums, and
for reviving their vitality, according to the case, either become
drained by an over irritation, or extinguished by a deleterious
cause, if we can speak thus, which affects the whole organic
system at once. We have so plainly described these different
means, in treating of the orders of diseases of the gums, of
which they are but the last expression, that it will not be neces-
sary to return to them here.
As to gangrene of the gums, resulting from a violent contu-
sion, as a blow, a fall, or of a too great pressure, as that which
might be the result of a badly arranged artificial plate in the
mouth, it causes a sharp pain, which at first precedes it, and
local signs that indicate it. It can only be cured, as we firmly
believe, by destroying the cause which produced it, accompa-
nied by the use of the means applicable to other cases of gan-
grene.
We, some years since, met with an example of this latter
kind, in a young man, aged seventeen years, whose two central
incisors of the lower jaw a dentist had endeavored to straighten
by the use of a double band, that he had badly adjusted and
pressed too tightly upon the alveolar border. The pain result-
ing from the application of this fixture was at first very acute ;
but the young man, believing it inevitable, had courageously
endured it. It suddenly ceased, and when we wished to judo-e
of the effect of the treatment, we perceived, added to a cadaver-
ous odor which exhaled from his mouth, a number of small
pustules, filled with a slate-grey pus, and two blackish eschars
which covered, upon each side, the projection that the roots of
the canines ordinarily caused upon the alveolar border, and that
the gums were, in a great measure, gangrened upon their anterior
face, being the one upon which the pressure had principally
been exerted.
Tumors of the Oums.
Tumors or Fungous Ejjules.—We give the name of epules to
a different kind of fleshy tumors which develope themselves
upon the gums, or in the depth of the alveoli. They are exces-
sively variable in form, nature and volume.
236 ANATOMY, ORTHOPEDIA,
Some are soft, fungous, supine and have a striking analogy
with the fungosities which we sometimes see formed upon the
surface of atonic ulcers and of decayed bones. They are of a
dark red, punctured with ease, and are filled with a purulent and
fetid matter, which is sometimes bloody. They are nearly
always occasioned by the decay or necrosis of a root of a tooth,
or by a portion of the alveolar border. We have also known
this species to be the result of the comminuted fractures of the
jaw, and to be continued by some necrosed splinters of bone.
Others are of a closer, more elastic tissue, and of a more livid
red ; they yield to a pressure, but instantly return to their
former position when the pressure is removed ; we feel the arte-
rial pulsations plainly there, and they are sometimes sensible to
the sight. These tumors are covered by the gummy membrane,
and their organization appears to be the same as that of the
erectile or blood-colored tumors. Before they have had an inci-
sion, they yield no kind of matter. If we incise them, an abun-
dance of red remillier, or of arterial blood, flows from them ;
they may result from contusions, or from no known cause.
We also meet with hard, rough, pale or violet-red epules.
Some of them are supine, others are the seat of a dull pain, or
of more or less acute shooting pains. These latter possess the
most troublesome character, and are most liable to degenerate
into a cancer. They are very common : the diflerent museums
of pathological anatomy, amongst others, that of the Faculty of
Medicine in Paris, possess many cases ; Fox relates a very re-
markable example, in his work ; we ourselves have met with
many in the course of our practice, among others, one smaller
than that of which Fox speaks, but yet of considerable size.
Ambrose Pare* speaks of having seen one of these excres
cences, so voluminous that "part of it appeared without the
mouth, and rendered the patient a hideous object." He says
he destroyed them, by first tying them with a very strong double
thread, and afterwards by applying an actual cautery, in order
to destroy the remaining part of the tumor. He adds, that this
tumor is often cartilaginous, and that it even, in time, becomes
* Book eighth, chapler fourth.
PATHOLOGY AND THERAPEUTICS.
237
bony. Fauchard has also given us an account of a case of this
latter kind, which he was called upon to treat.
Epulesare developed much oftener upon the inferior than upon
the superior jaw ; they may form upon the anterior and posterior
parts of the gums, or between the teeth, in the empty alveolus,
or, finally, upon the internal side of one of the branches of this
jaw, of this latter kind. Begin gives us an example.* The
volume of these tumors, as we have already observed, is ex-
tremely variable; some scarcely equal a pea; but others, as
we shall quote examples, exceed a large nut, and even acquire
an enormous dimension. Finally, we see epules proceeding
from the gums, filling the cavity of a fractured and decayed
tooth, covering it, and even binding the crown, so as to form
upon its sides a thick cap, which hinders mastication, and pre-
vents the complete occlusion of the mouth.f
Their form presents as much variety as their volume. Some
are round, projecting and supported by a pedicle; others are
equally round, but supported by a large base ; others, finally,
project but little, but are very extended in surface, and adhere
largely to the gums, in such a manner as to be able, by a super-
ficial examination, to be confounded with a simple swelling,
generally with that which has no evident inflammatory charac-
ter, as when it is the product of the action of mercury or of
a scorbutic or scrofulous affection. But, in these three last
cases, they are not decided tumors, which form upon the gum,
or arise in the depth of the alveoli, between the teeth and the
gum, or between two neighboring teeth ; they are true tume-
factions of the whole of the gums, which become spongy and
bloody.
We distinguish epulis from an abscess of the gums, in this
way, the progress of the latter is, in general, more rapid, and
follows an inflammation which takes place previous to its forma-
tion. An abscess is accompanied by a fluctuation which epulis
generally is not, however soft it may be. It is not possible to
confound this disease of which we are now treating with the
* Work quoted, vol. 1st, p. 236.
t Dictionary of Medicine, article Epulis.
238 ANATOMY, ORTHOPEDIA,
sarcoma of the maxillary bone, because epulis is not accompa-
nied by the swelling of this bone, and we cannot introduce, by
the pedicle of the tumor which it forms, a stylet, as far as the
maxillary sinus, as this is the case when this tumor depends
and forms part of the sarcoma of the superior jaw. As it regards
the exostoses of the alveolar depths, it can easily be recognised
by percussion, and thereby prevent it from being confounded
with epulis, even with those which have a firmness nearly car-
tilaginous.
Epules may, to a certain degree, hinder mastication, and op-
pose the clearness and even the possibility of pronunciation ;
they loosen the teeth, and compel them to deviate from their
true position. They may, according to their nature, remain sta-
tionary a long time, or develope themselves and rapidly enlarge,
ulcerate, exhale a fetid odor, occasion the engorgement of the
lymphatic sub-maxillary glands, and even give rise to a can-
cerous affection of the portion of the bone to which they corres-
pond. Dr. Lachaise has related to us an instance of a woman,
inhabiting the village of Vigey, with whom an enormous epulis,
ofa soft and spongy nature, unceasingly covered with a puru-
lent matter, had occasioned a great change in the digestive or-
gans, and a kind of aneuric cachexia, against which every
remedy failed, but which disappeared rapidly by the ablation of
the tumor, and by the cauterization of the surface that it occu-
pied in the superior jaw. No doubt that the purulent absorption
was the cause of the general disorder of the economy, and it is
evident that this disorder yielded to no other means than the
destruction of the epulis.
Notwithstanding all that which we have said of epulis, that
these are not, in general, serious affections, they are as easily
cured when brought on either by decay or necrosis of the max-
illary bone. In both cases, they cease to reproduce only when
the diseased part of the bone is restored to its natural state, that
is to say, when the decayed part of the bone is destroyed, and
when the necrosis is exfoliated, as we shall prove by the obser-
vations we shall make in speaking of necrosis of the alveolar
border.
Their treatment is, of necessity, deduced from the facts which
PATHOLOGY AND THERAPEUTICS. 239
we shall state. Thus, symptomatic epulis, resulting from the
decay of one or of more roots of teeth, disappears, sometimes,
after the extraction of these latter ; but it is always more pru-
dent to extract them with a bistoury, or with scissors crooked
upon the side ; also, after the extraction, to await the sponta-
neous-bleeding. A moderate flowing only of blood, after this
operation, may be advantageous; we can make it cease at pleas-
ure, by the use of alcoholic or slightly astringent gargles, or still
better, by a moderate pressure, exerted some minutes.
Erectile and pedicled epules may be tied or excised ; if their
pedicle is straight and sufficiently elongated, so as to permit the
finger to pass behind it, it can be torn or pulled off; Begin
gives us an example of this; he thus expresses himself: "A
young officer, who came to consult us, from the Val-de-Grace,
had, for some months, an epulis, whose size equalled the egg of
a pigeon, situated upon the internal side of the right branch of
the inferior maxillary, which covered, in some degree, the
tongue, and thus impeded its movements. By examining the
tumor, I found it supported by a pedicle so straight and so yield-
ing, that, by passing my finger under it, so as to form a crotchet,
1 broke it without any efibrt, and it fell from the mouth. After
a considerable flowing of blood, the patient departed, and expe-
rienced no relapse."
If, on the contrary, they have a large base, we should extract
them carefully, with a cutting instrument ; and, in every case,
it is necessary to cauterize the surface from whence they were
removed, as much to prevent their reproduction, as to arrest the
hasmorrhage which habitually follows the operation. Cau-
terization, performed by means of iron, heated red hot, merits, in
this case, the preference over that which is effected by chemical
agents, because it is more prompt, easier to limit, of a readier ap-
plication, less painful, and principally because it prevents, more
certainly, the return of the disease. The following observation
confirms the justice of this assertion.
In 1832, a lady, from forty to forty-five years, consulted us in
regard to an artificial plate, by means of which she desired to
replace four teeth, which were wanting upon the right side of
the inferior jaw. The space that the lost teeth had caused was
240 ANATOMY, ORTIIOPEDIA,
filled by a fleshy tumor, large at the base, which appeared to be
only the result of the thickeningof the dental alveolar membrane.
We proposed to her that we should first remove this tumor ;
but she preferred that a physician should perform this operation.
He removed it effectively with a bistoury, and believed, after
frequently applying nitric acid, that he had destroyed the parts
which had escaped the instrument. Three months after, she
again returned to see us, and we found the place that the tumor
formerly occupied, covered with small lardaceous tubercles, of
a cancerous appearance. We then learned that cauterization
had been effected by means of nitric acid, whose effects were
limited with much difficulty each time. We advised, without
hesitating, the cauterization of this diseased surface with red hot
iron. The patient consented; a month after, the toothless
space had cicatrized, and we were able to apply there a plate,
which gave no inconvenience.
Tumors or Scirrhous Epules. — Hard, rough and scirrhous
epules are those which deserve the fixed attention of surgeons,
as they may have dangerous consequences. It would be un-
safe to await, in order to remove them, until they become very
large, painful and ulcerated; their complete extirpation cannot
be effected too soon. After having carefully removed them
with the bistoury, and cleaned with precaution the surface of
the alveolar border, if there are any adhering portions, it will be
necessary then, more than in any other case, in order to prevent
their reproduction, to cauterize the surface of the wound with
red hot iron. In regard to tumors of this nature, which have
been abandoned too long to themselves, or exposed to improper
treatment, which may change the bone to a considerable extent,
we are obliged to make a resection of a portion of the maxillary
bones. Professor Lisfrance was compelled, recently, to resort to
this means.
In May, 1840, we saw, in the service of Valpeau, to the
Charite, a man who had, upon the alveolar border of the supe-
rior jaw, an epulis, which he attributed to the extraction of a
tooth, the operation being performed in his fiftieth year ; the
epulis was constantly reproduced, notwithstanding it was be-
lieved to have been destroyed several times, either by the bis-
PATHOLOGY AND THERAPEUTICS. 241
toury or by caustic. Valpeau employed, in order to remove it,
a kind of excising forceps, the end of which was bent upon the
side, nearly horizontal to the two branches, it was very convex
outwardly, and terminated by two hollow cutting edges in-
wardly, in such a manner as to present a concavity large enough
to contain the parts which should be removed. These pincers,
appplied upon the diseased alveolar border, removed, by a single
effort, all the affected portion, which included at once the soft
and bony parts. The amputation or resection of the jaw is thus
sometimes avoided.
Tumors of this nature arise, very often, in the alveolar tissue;
we shall proceed, then, to the description of the diseases of the
alveoli, to which they seem particularly related, although, in
observing them with much attention, we discover that they
often arise, if not from the tissue of the gums themselves, at
least from the membrane, which, after having lined them, enters
in the alveolus, and from thence into the subjacent osseous
meshes.
Diseases of ike Alveoli.
The Hghtness with which most authors who have written
upon our art have treated of the diseases of the alveoli,* must
astonish physiologists, who consider, as we ourselves have done,
in our anatomical part, these bony partitions as belonging more
particularly to the teeth than to the jaw bones. Practitioners,
whose daily experience teaches them that they are nearly
always affected, in a direct or sympathetic manner, by the dis-
eases of the teeth and gums, and that they are, moreover, ex-
posed to particular morbid states, so important as to deserve
serious attention, must, above all, be surprised at this negligence.
We judge it proper to examine them in the different pathologi-
cal states which are most commen to them, such as their primi-
tive narrowness, or their impeded development, and its conse-
quences, the inflammation of their membrane, their extreme
thickness or wearing away, their fracture, and, finally, their
necrosis and cancer, etc.
* Maury does not speak of them ; Lemaire says very little; Lefoulon doea
not say a word, etc. etc.
31
242 ANATOMY, ORTHOPEDIA,
The Primitive Narrowness of the Alveoli. — Nature has, very
certainly, arranged and disposed all things for the easy and
regular execution of all the functions of the organism : expe-
rience, however, proves that a number of circumstances may,
even in the course of foetal life, oppose themselves to the ivQQ
development of certain parts, and thus produce a very promi-
nent obstacle to the execution of the functions which belong to
themselves, or to other organs to which they are united by the
designs of a common end. It is thus, for example, that the
uterus may be perfectly formed, and the accouchement rendered
difficult, or even impossible, only by the congenital narrowness
of the bony opening of the basin through which the product of
conception must pass, etc.
May this not, then, be the case with the germs of the teeth,
and the bony cavities which they must pass ? However remote
it may be from our intention, to participate in the exaggeration
that generally reigns in regard to the estimation of the phe-
nomena of dentition, we are, nevertheless, obliged to admit,
with Baume,* against the plain but too exclusive opinion of
Laforgue,f that, in some cases, the gums are not the only ob-
stacles which oppose the efforts which the teeth make to appear.
In effect, the too contracted superior borders of the alveoli, that
is to say, the narrowness of the passage through which the teeth
must pass, may also be an obstacle capable of perpetuating the
pain, until it is insurmountable, and of increasing the other ac-
cidents so much that we are compelled to employ means which
may be more hard and more painful than the simple division of
the gums, yet they do not constitute a terrible operation, as the
last author that we have quoted would have us believe.
The resistance occasioned by the gums, and the narrowness
of the alveoli, are two cases, doubtless, difTicult to distinguish;
nevertheless, with attention and the habit of close observation,
we may discern them. Although the gums, on account of their
density, resist the action of the teeth, and oppose their cutting
through them, we see, notwithstanding this obstacle, the teeth
* Treatise upon First Dentition, Paris, 1806.
t Theory and Practice upon Ike Jlrt of the Dentist, vol. 2, p. 263.
PATHOLOGY AND THERAPEUTICS. 243
forcing themselves without their alveoh, advancing and pushing
the gums towards the interior of the mouth, because they resist
the action which tends to divide them ; they yield, nevertheless,
to the impulsion that these organs exert upon them.
This phenomenon, which is very apparent, says Baumes,
does not take place, when the obstacle depends upon the nar-
rowness of the orifice of the alveolus. The resistance that
affects the edges of this orifice prevents the tooth from elongating
from the side of the gums, and pushes them before it. The
efforts which the teeth make to this effect, reacts upon the
depths of the alveoli ; the periosteum which lines these small
cavities is compressed and bruised by it ; the fillets of nerves
which belong to each root are drawn and irritated by it ; violent
pain results from it, and consecutive accidents sometimes mani-
fest themselves in the most unquiet manner.
In this latter circumstance, the gums which cover the alveo-
lar border appear every where equal ; no part of their surface is
elevated, because the teeth, being retained in their alveoli, can-
not affect them. Finally, the exclusion of the signs, which we
meet with in the first state, might appear sufficient to induce us to
suspect that of which we are now treating. The alveolar orifice
does not always form, by its contracted border, a circular barrier,
which opposes the progress of the teeth ; sometimes, only one
part of this border is an impediment, whilst the other, more de-
pressed, does not cause any hindrance. In this case, the tooth
may appear towards the tongue, but it appears in an improper
place, and cuts through upon the side which offers the least resist-
ance; this may be one cause of so frequent an irregular denture.
We will now briefly notice, with Baumes, that the cases of
which we shall now speak, and which may cause serious acci-
dents, are, fortunately, very rare ; but the bare possibility of
their existing at all is sufficient to impose upon us the necessity
of calling the attention of young practitioners to them.
Thus, then, if after having incised the gums, we perceive that
the obstacle impeding the cutting of the teeth proceeds rather
from the contracted alveolar orifice than from the density of the
soft parts, we are satisfied that the division of these latter would
not allay the unquiet symptoms; it is necessary to take another
244 ANATOMY, ORTHOPEDIA.
course ; this must be the removing of the osseous parts of the
alveohis, which constitute the obstacle. In order to accomphsh
this, we should employ cutting pincers, and we might better ex-
tract this osseous part, from its circnnifereiice, by scissors. Tliis
part is not very resisting, and can be removed with little force.
The tooth then possesses the power of advancing, and the
snbjacent periosteum being no longer compressed, the accidents
which result from this compression appear only in a feeble de-
gree, or are dissipated altogether.
The Ivjiammation of the Alveolo-deiital Periostemn, and Al-
veolar Cysts. — The alveolar borders, as we know, are lined,
interiorly, with a vascular membrane, analogous to the perios-
teum of the other bones. This membrane may, under the influ-
ence of a number of causes, become the seat of an inflammation,
acute or chronic, and whose termination may be a complete
resolution, a purulent flowing, or the formation of a true phleg-
masia. It may also furnish the constituent elements of a cyst.
In the acute state, this inflammation is characterized first by
a dull pain, then piercing and pulsative, appearing round the
healthy tooth. The gum soon swells and becomes red and
painful, the swelling even reaches sometimes the jaw. A state
of vacillation follows, which is more apparent in this than in
any other aff'ection ; this state is so obvious to the patient, that
he imagines either that it will drop out of itself, or that it may
be extracted by the slightest effort.
This is an error that must be opposed in every instance ; for
this vacillation, which appears so great, is none other than the
natural movement, which, although insensible in the normal
state, is rendered apparent by the augmentation of the sensi-
bility of the periosteum, and the admittance of the fluids which
engorged it tends to remove the alveolar walls ; the teeth are
not then less solid or less diflfilcult to extract.*
♦This explanation will suffice to destroy, in the case, unfortunately so
common, where extraction is absolutely necessary, the hope that the patient
may have indulged in, viz. that he will not have to endure the operation,
and prevent him from accusing the dentist of having been the cause of
pain which they might have believed would not have been necessary if this
explanation had not been made.
PATHOLOGY AND THERAPEUTICS. 245
When this inflammation is chronic, it is ordinarily induced
by some internal cause, such as a scrofulous, scorbutic, vene-
real or rheumatic state. Between the teeth and gums, then,
there is formed puriform and fetid matter, which loosens the
former and softens the latter. In this case, the affection is
sometimes very difficult to cure ; it ordinarily causes the con-
sumption of the roots, as we have already said, and sometimes
the destruction of the alveolar partitions, as we will soon see.
The treatment of this disease varies, according as it is acute
or chronic. In the first case, it is remedied, as all the affections
of the same nature, by emollient and narcotic gargles, by leeches
placed below the angles of the jaws and even upon the gums,
by foot-baths, and by lukewarm and emollient drinks. During
the chronic state of the disease, it is important to wash the gums
frequently, with liquids aromatised by bitter, astringent and
spirituous liquors. It is sometimes requisite, in order to arrest
the disorganizating work which consumes the roots, to apply a
a cautery or blister upon the neck or behind the ears.
Cysts, which develope themselves so frequently upon the
maxillary bones, form a kind of affection, of the existence of
which the ancients were completely ignorant. Bordenave*
made some conjectures respecting them, but Hunter in his
works, and Dupuytren in his anatomical researches, give unde-
niable proofs of them. M. A. Forget has recently made them
the subject of an introductory lecture,t and of a very interesting
treatise.J
These cysts contain solid matter or simply liquids, as of se-
rosity, either pure or mixed with blood, of pus, of hydatids, and
of mucous matter. The first, much more common to the infe-
rior than to the superior jaw, occupy the small areas of the
spongy tissue, whilst the second, that is to say, those which
contain the liquid products, are more superficially situated, con-
sequently they border upon the alveolar ridge, and devolope
themselves, in a great number of circumstances, in the alveoli.
Doubtless that, in this case, their walls are not formed by a
* Work quoted,
t Thesis before the Faculty of Paris, 1840.
J See Gazette of the Hospitals, 27th of August, 1840.
246 ANATOMY, ORTHOPEDIA,
prolongation of the alveolo-dental membrane. Many facts
confirm this opinion. The most prominent is that of the ex-
traction of the first small molar, whose two roots carry with them
a vesicle of the size of a large pea. We believed, at first, that
this was one of those fleshy tnmors, a kind of vegetation with
which the extremities of the roots are so often furnished; but,
by examining it with care, we attributed it to fluctuation, and,
having opened it, a viscous fluid escaped, and, by the use of
the microscope, we discovered some hydatids. By probing the
place which this tooth had occupied, we perceived a vast oblon-
gated cavity, and altogether proportioned to the volume of the
tumor. The patient had experienced only an obtuse pain,
whose continuity, more than its intensity, had induced him to
have the tooth extracted, and the augmentation of the thickness
of the alveolar border, in the corresponding portion, was made
in a manner so progressive, that it was not perceived by him
until it was very prominent.
Exostoses of the Alveoli. — The alveoli may, as all the other
parts of the osseous system to which they belong, become the
seat of a swelling, or of an enlargement of volume, as we have
said in regard to the teeth.
This pathological state, confined to a single point, and cir-
cumscribed in its form, constitutes a true exostosis. This
is sometimes the case with that part of the alveolar border
formed by the union of the superior maxillary bones. Then the
central incisors, generally situated very near, commence to
separate in such a manner that a tooth appears to have been ex-
tracted between them. This circumstance affects, sometimes,
the symphysis of the inferior jaw.
The tumefaction of the alveolar partitions, instead of being a
true exostosis, may be a simple increasement of volume. Fox
relates a case of this kind, in which these partitions were so
large, in the posterior part of the superior jaw, where the molars
only existed, that the jaw appeared to be swollen, thus causing
a great deformity. He extracted the teeth, hoping that the
tumor might be diminished by the absorption of the alveolar
partitions, an absorption which is always the result of this ope-
ration. The tumor diminished, and the progress of the disease
PATHOLOGY AND THERAPEUTICS.
247
was arrested. This example may serve as a guide in similar
circumstances.
As it regards exostosis properly called, we believe that the
extraction of the tooth corresponding to the alveolar partition
upon which the tumor is developed, will be the only course to
pursue, if this latter constituted a serious deformity, or impeded
either the movements of the tongue or the lips. The result
would be one of the following two : either, by the extraction of
the tooth, the portion of the exostosed alveolus would separate
with it; or, if this remaining portion remains, the oblitera-
tion of its cavity will be effected by the approximation of
its edges.
Independently of the two kinds of exostoses that we shall
describe, and which exist, viz. the first in a thickening of the
alveolar partition, and in a kind of accumulation upon some
part of their walls, of an exuberant quantity of calcareous salts ;
these cavities may be either the seat, or the point from whence
a soft or spongy tumefaction proceeds, which Astley Cooper
has named fmigous exostosis, and of which he gives the follow-
ing example :
"William, aged thirty-two years, came frequently to the con-
sultation of the Hospital of Guy. He had, in his inferior jaw,
a futigous exostosis, which caused a large projection in his
chin. The tumor had commenced six years before, by the
vacillation of the teeth, followed by their loss. Upon the
alveolar cavities, fungous productions appeared, of a violet
red color, which, after a certain period, gangrened and disap-
peared ; then the gums cicatrized. The jaw now commenced
to tumefy, the fungus re-appeared at the expiration, of about
two years, and again disappeared. At this period, the maxillary
hone could be penetrated even to the top of the chin. A volu-
minous tumor formed from thence, upon a level with the sym-
physis, and gradually increased, accompanied with little pain.
Finally, the skin of the chin is ulcerated ; the fungus projects
forward by this ulceration, and two other red and violet projec-
tions appear upon the gums."
This is the same kind of affection that Doctor Hugier, ad-
mitted surgeon to the faculty, called areola?' exostosis. He has
248 ANATOMY, ORTHOPKDIA,
submitted many cases to the royal academy of medicine, and
he has given a remarkable one to the hospital of the school.
The following is a summary of it:
Maria Marg. Foiret, aged exactly sixteen years, had a violent
fall upon her face, in her sixth year. During the first six
months, she experienced pains in the right superior molars ; but,
at the expiration of the year, a hard and very painful tumor ap-
peared in the canine fossag, between the jaw and the molars; it
increased slowly until it acquired the size of a large orange, with-
out, however, being followed by any pain. When the interior
of the mouth was examined, the right alveolar border was thick-
ened, depressed and thrown outwardly, and in consequence of
the development of the tumor, the face was deformed and the
mouth could not be closed. Her general health, however, was
good, and no engorgement of the lymphatic glands, neither of
the head nor neck existed.
Although this affection had a great analogy with osteo-sar-
corna, Hugier, however, did not doubt its nature. He, never-
theless, made a puncture, from whicli only a few drops of pure
blood issued ; he then extracted the incisor, and the first of the
two molar teeth which remained, preserving the latter which
belonged to the healthy parts and which served, at a later period,
to prevent the inferior jaw from sinking to the right. Finally,
after having made an oblique incision in the inferior and poste-
rior angle of the bone of the cheek as far as the superior lip, in
order to manage the fillets of the facial nerve and excretory duct
of the salivay gland, he exposed the tumor, divided the mental
apophysis of the maxillary, and os unguis, with the gouge and
mallet, separated the bone from the cheek of the zygomatic
apophysis with a circular saw, finally detached the anterior
and inferior part of the maxillary partition with a pair of scissors.
The Wearing Away or Absorption of the Alveoli.— This organic
change, altogether opposed to the exostoses of the alveolar parti-
tions, consists of their disappearance, or the gradual absorption of
their substance. As this change generally takes place from the
fortieth to the fiftieth year, a period when man has always passed
the meridian of life, one is led to believe that it is the natural
result of old age; and if it happens sooner, as is generally the
PATHOLOGY AND THERAPEUTICS. 249
case with the alveoli of those teeth which cease to be united, we
believe it can be explained in this way, that the empty alveolus
approaches its walls and becomes absorbed in its ridges. But
this pathological state can no less exist as an affection indepen-
dent of the two causes that we have mentioned, viz. the age and
vacuity of the alveoh.
When the alveolar ridges are effected by absorption, the gums
of which they are the support, partake inevitably of the effects
of this disease. In effect, in proportion as the osseous substance
of the alveoli diminish, the gums cease to be united with the
teeth, the necks of which are exposed and which appear to grow.
When this change takes place in the alveoli in the two jaws, the
teeth not only appear to lengthen, but seem to be still more dis-
tant from each other than heretofore ; in the mastication of hard
substances, also, becomes much more difficult.
When once this condition takes place, the tooth vacillates,
elongates and becomes inconvenient, because it prevents the
use of that side of the jaw which it occupies, so much so that
its extraction is necessary ; but another tooth soon experiences
the same fate, and then another, until the jaws are deprived of
all the teeth. Sometimes, nevertheless, the absorption is con-
fined to two or three teeth, the alveolar partitions are effected only
in part, and after the extraction of these teeth, no other indica-
tion of the disease remains.
The abandoning of the root by the alveolar border, and the
gum to which this latter gives strength, may be only the result
of the absorption of the alveolar ridge; but very often the tooth
is forced from its osseous socket by another cause, viz. the con-
traction of the alveolus which it fills. Fox treats of this diseased
state separately; this is an error according to our opinion ; for
as his translator justly remarks, this contraction rarely takes
place without being preceded or at least without accompanying
absorption, it is probable that both are produced by the same
cause ; that they are two characters of the same disease, or, if
we prefer it, and this seems to us very admissible, two simulta-
neous results of a disorganizating work by which the alveoli
are affected and the natural tendency that they possess to oblite-
rate themselves by the approaching of their walls as soon as they
32
250 ANATOMY, ORTHOPKDIA,
cease to be occupied by the teeth, or that they, by the loss of
their vitality, are reduced to the state of inert bodies.
The disappearance of the alveoli, as an affection independent
of the progress of age of the vacuity of their cavities, has been
a long time a constant and incontestible fact to us ; for we have
met, as partsof pathological anatomy, many inferior jaws which,
by the obliquity of their branches, the small development of
their muscular parts, the length of the wisdom teeth, denot-
ing clearly that they belong to young subjects, and upon which
also the destruction of the alveolar borders, as far as the body
even of the bone, proved that the cavities of this border was de-
prived, had disappeared, under the influence of some other
cause than the simple approximation of their walls. But
although nothing from thence proves that this disposition had
been the result of a disease of the gums,of thealveolo-dental pe-
riosteum, or of an affection of the roots of the teeth which com-
municate so easily to their osseous envelopes. The following
fact destroys all doubt upon this subject : a man from thirty-six
to thirty-eight years of age, removed some months since to Paris,
after having inhabited a long time the colonies, and came to
consult me in relation to many teeth of the inferior jaw, which
were so loose that he believed that he should lose them. Sup-
posing that this fear on his part was only the effect of a sensi-
bility excited by the parts in the midst of which the teeth were
placed, I assured him of it at first ; but having examined them
with more attention, I perceived that they were not really held by
the jaws ; for, so to speak, nor by the adhesion of the gums to
their necks which were completely exposed, but by the con-
nection of the gums to their roots which were abandoned by
their osseous sockets. The gums were of a vermilion color,
but neither bloody nor tumefied, and a pressure exerted upon
them did not cause any puriform fluid to escape which might
lead us to believe in the existence of disease in the periosteum.
Being convinced, then, that there was no hope of saving the
teeth, we did not hesitate to advise the extraction of them,
in order that by so doing the patient would escape the pain
which their presence would cause. This counsel was fol-
lowed ; the gums soon sank down even upon the body of the
PATHOLOGY AND THERAPEUTICS. 251
maxillary deprived of its alveolar border, and, six months after,
artificial teeth, with colored gums, were applied without causing
the least pain.
We have not considered as yet the disappearance, or the ab-
sorption of the alveolar partitions as a primitive state ; but that
which we shall now say, will demonstrate this change may, it
is also frequent, depend upon a chronic inflammation of the
gums transmitted to the alveolo-dental periosteum, and from
thence to the osseous tissue itself, which causes a disorganizing
work to proceed more easily than it is naturally disposed to do.
We meet with this very frequently among persons whose teeth are
covered with tartar, and with those whose gums are the seat of an
intense scorbutic affection. The single designation of the cause,
in these two cases, suffice to make known the therapeutic indi-
cation. We have a specimen which proves, also, that, in this
kind of absorption, theeff"ects are not always equally felt by the
external and internal walls of the alveoli ; for in this specimen,
the osseous portions, by their disappearance have completely ex-
posed the roots of the anterior teeth, whilst they are untouched
backwardly.
Fractures of the Alveoli.-— The fracture of the alveoli without
being a very common accident, is, however, a very frequent
one : all the causes which may occasion the fracturing of the
teeth may also cause that of the alveoli. Exterior violence,
as blows, falls, directed immediately upon the teeth, frequently
do not effect but occasion serious disorders in the alveolar bor-
der ; this may be explained by the concussion which the al-
veoli receive from the roots and which is often so great as to
fracture them.
When these fractures depend upon the causes that we have
mentioned, they ordinarily affect the exterior wall of the alveo-
lar partition, because the blow, taking effect first inwardly,
then outwardly, acts upon the crown of the tooth in the
mouth, and then reacts upon the root in a contrary manner.
In elementary language, we would call these fractures, indi-
rect fractures or contra bloiDS, hi opposition to those resulting
even from the pressure of the neck of the tooth upon the
alveolar border, would affect this border inwardly and therefore
be direct.
252 ANATOMY, ORTHOPEDIA,
But of all the causes of these fractures, one of the most com-
mon, it is necessary to say it, although not a very flattering ac-
knowledgment from our art, is a badly performed operation in
the mouth, and, if it is necessary to specify cases, we would not
hesitate to quote, in the first place, the use of the key of Gar-
engeot ; for we can prove, in treating of the extraction of teeth,
that this dangerous instrument, which is only fit to mask the
unskilfulness of the operator, to the detriment of the operation,
is one of the most defective of surgical instruments, and that no
workman of good sense, being convinced of its mode of action,
would attempt to employ it if he wished to extract a nail from
a hole if he did not desire to break the wall.
Whatever may be the causes of these fractures, to which the
alveoli may be predisposed by the fact of a pathological state, it
is always prudent to seek to reunite the separated osseous parts,
particularly if the fracture occupies a large space, if the gums
still retain the fragments in place, and more particularly, finally,
if these fragments are attached to one or more teeth, whose loss,
we do not cease to repeat it, is always a serious event. The
reduction of the parts being affected, it is sufficient, in general,
in order to maintain them in place, to press them lightly by a
piece of linen, rendered fixed by a metallic plate, or by a thread
of silk passed many times around the neighboring teeth.* But
if it is a comminuted fracture, it would be better to remove
the splinters and to oppose local accidents by ordinary anti-
phlogistic means.
One of the most extraordinary cases that we have met with, is
that of a young officer of cavalry, who fell from his horse with
his face upon the ground. The six lower anterior teeth, having
received all the effect of the fall, were driven inwardly, without
being fractured, but their roots broke the anterior walls of the
alveolar border, not only in the space that they occupied there,
but as much on the other side, in a horizontal as in a vertical
direction. The military surgeon was immediately called in,
having the hope not only of preserving the fractured osseous
* We are far from giving this advice as new, for we give it in the same
words (but translated) as Hippocrates.
PATHOLOGY AND THERAPEUTICS. 253
parts, but the teeth which were adherent to them, constructed
a fixture of tin, which enclosed the dental arch and the alveolar
border, was attached to the last large molars. The patient soon
experienced a dull pain, and, shortly after, a purulent and fetid
flowing commenced from beneath the fixture.
At this period we were consulted. As soon as we could ex-
amine it, we did not doubt but that the consolidation of the
fractured parts had not taken place, and we immediately advised
the removing of the fixture. We then found the gums horribly
tumefied, and by pressing lightly upon them we caused the os-
seous fragments to move about, and a great quantity of pus to
escape. Our first care was to separate the soft parts, which re-
tained the splinters, and to extract them. Cicatrization soon
followed. At a later period, we made him an artificial plate,
which perfectly concealed the great loss of substance which was
the result of his fall.
Necrosis and Cancer of the Alveolar Border. — When the alveo-
lar border has been broken by any cause, we perceive very
plainly, as we shall demonstrate, that the portion which has
been fractured may remain adherent to the rest of the bone,
and may finally consohdate there in a definite manner. But
very often this portion mortifies for want of sustenance, in a
word, it nec7'oses, and finally separates altogether from the
maxillary.
The fractures of the alveolar border are, then, the most fre-
quent causes of their necrosis.
These are, at least, the most frequent cases that we have met
with, for we have nearly always been able to discover that, from
periods more or less anterior to the time when we had noticed
the necrosis, the patient had undergone some operation to which
it was rational to attribute it to. But it is no less true that a
portion of the alveolar border may be necrosed, without having
been primitively fractured, or without our being able to discover
the true reason of it.
This pathological state had not escaped the observing mind
of Hippocrates, as the following phrase proves : "After some
pain that the son of Metrodore experienced in his teeth, a great
tumefaction of the gums followed ; they suppurated a little, a
254 ANATOMY, ORTHOPEDIA,
portion of the gum detached itself with the molars which were
implanted there."*
Some years since, we ourselves met with an instance in which
we extracted, for a youth of seven or eight years, apprenticed to
a shoemaker in Planche-Mibray street, a canine and the two
small superior molars upon the left side, to which a considerable
portion of the maxillary adhered, which, unfortunately, contain-
ed the germs of the secondary teeth. After an attentive exami-
nation, we were induced to attribute this accident to a scrofu-
lous affection, of which he bore the marks.
This species of necrosis is sometimes also the result of a state
of extensive deterioration, into which some infants are thrown
by some eruptive disease. Duval relates a curious case, result-
ing from the small-pox, thus :
"M. Boyer and myself had occasion to see a similar case, in a
little girl of seven years ; she had had, in July, 1807, the small
pox, which, by its complicated or bad character, required the
application of blisters upon the legs. An abscess, which was
upon the maxillary bone of the right side, appeared to have
been the termination of the disease. At first they considered
it as fluxion, and paid it little attention ; the disease having,
however, progressed, although slowly it is true, and which they
thought might perhaps result in the death of the child, we were
consulted about the commencement of January. By examining
the interior of the mouth, we easily discovered that a portion of
the maxillary bone was necrosed; the bone was denuded an
inch or more, and we perceived the two milk molars shaking in
their sockets.
Being persuaded that nature alone, in this case, would be
the best physician, we were content to try its care, whilst
we seconded its efforts. The pure air of the country and
much exercise, assisted much in the cutting of the incisors,
and, at the end of July, that portion of bone that was necrosed
yielded to the feeble efforts of his hand, and by its removal
caused a complete cure. The osseous fragment which was de-
tached had in it nearly fifteen lines ; its form was irregular, in
* De Morbis Vulgaris, fifth book.
PATHOLOGY AND THERAPEUTICS.
255
consequence of these asperities. This fragment was the middle
portion of the alveolar arch, into which were implanted, at the
time of its removal, the two milk molars. Between the roots of
the teeth were also embodied in their alveoli the crowns of two
small molars of replacement, whose roots were not yet com-
pleted."*
There was, in the Charite hospital, (in December, 1842,) a man
who was also an example of this. Let us observe the state of
this patient, and the summary of the clinical lecture of Valpeau,
of which he was the subject ; a summary which gives, at the
same time, a description of the disease, and the indication of the
disease which is applicable to it.
At his entrance into the hospital, this man had, upon the
right side of the alveolar border, a tumor, dated from six to ten
months, and whose origin was obscure. He related that he
had experienced, towards this last period, a pain in the right
ride of the jaw, but without having had any of the teeth defaced.
A very considerable swelling followed, which, after many
months, formed a tumor, of which the termination was a puru-
lent collection. If a tooth had been extracted during this tume-
faction, the pus would have passed through the emptied socket,
and the pain would have completely ceased.
This man was pale, but did not, however, present that yel-
lowish tint, the indication of cancerous cachexy. It appeared
that he had, also, in the origin of his disease, an engorge-
ment under his jaw, but which had completely disappeared ;
we did not find any trace of the absorption or wasting away of
the tissue. Between the canine and the molars of the inferior
border of the right side, we remarked a slope, caused by the
absence of many teeth ; it is in place that we, by a light pres-
sure, caused the pus to flow. We perceived there, also, a hard
grey plate, which was a portion of tumefied bone. This piece
of bone might have been taken for an old root, if we had not
distinguished there the alveoli, which did not permit us to doubt
the necrosis of a part of the jaw. By examining attentively, we
assured ourselves that it was not the alveoli from whence the
* Historical Researches upon the Art of the Dentist, etc.
256 ANATOMY, ORTIIOPEDIA,
pus departed, since the patient also assured us that he very
plainly perceived the pus gliding between the gum and bone
itself.
Valpean assured us of it more directly still ; he glided a sty-
let between the parts that we have mentioned, and met a con-
siderable portion of the bone of the jaw completely denuded.
It was not possible for us to know precisely to what extent
the denudation existed. All that we know is, that, notwith-
standing the considerable depth to which the stylet had pene-
trated, the disease did not appear to reach the maxillary tissue,
for nothing, in this place, indicated the mortification of the bone
itself. The treatment of a simple necrosis, and of one compli-
cated of a cancerous affection, should be altogether different.
If the necrosis is simple, the operation may be simple, and the
consequences scarcely dangerous ; but a cancerous affection is
followed by serious consequences. The following we believe
to be very nearly the words by which the honorable professor
has sought to establish his diagnostic :
"Cancers of the jaw ordinarily commence by the appearance
of some morbid growths, without any pain ; an acute pain may
follow suppuration, but never precedes nor accompanies the
character of the true phlegmon. When the pus creates a pas-
sage, the tumor does not disappear from that, but the tissues of
the region harden, and fungosities soon appear. Now, in this
kind, the pain has preceded the swelling, and this swelling has
been rapid, and transforms into an abscess. It then has all the
symptoms of a purulent inflammation. When a tooth has been
extracted for the patient, the pus proceeds out from the empty
socket, but there the tumor has diminished in volume, and,
finally, the disease exists under the form of a suppuration,
brought on by its sequestration. There is, then, every room to
believe that this disease is a simple necrosis, and not a cancer-
ous tumor, and that the cure may be easily made." The con-
sequences have proven that this judgment was correct.
As it regards the cancer of the alveolar border, we may add
to that which Valpeau has said, that it commences either by
the soft parts, or by the bone. In the first case, it attacks, first
the lip, and from thence proceeds to the jaw, for the same rea-
PATHOLOGY AND THERAPEUTICS. 257
son that a cancer of the breast attacks the sides ; in the second
case, it commences from a small, soft, fungous tumor, in the
depth of the alveolus, after the extraction of a tooth, and declares
itself, ordinarily, by the non-effect of excision and cauterization.
All that we can say, in this respect, is, that the only proper
course of treatment, is the extraction of all the affected parts.
The conduct of Valpeau, quoted upon a preceding page, may
serve as an example for the operator.
33
PART SECOND.
OPERATIVE MEDICINE AND PROSTHESIS, OR MECHANI-
CAL DENTISTRY.
CHAPTER I .
OPERATIVE MEDICINE.
Op all the organs which nature, on account of their diseases,
placed in the special domain of surgery, there are none, assur-
edly, with which this branch of the therapeutic art has more to
do than with the teeth. From the incision of the gums, the ob-
ject of which is to facilitate their eruption, to that extreme remedy,
their complete extraction, the operations to which they are sub-
mitted, form an immense field; and the cultivation of this field
requires so much the more exact knowledge and skill, because
the resuhs are appreciable to all ; and because errors when they
are committed, not remaining buried in the thickness of the tis-
sues, are exposed to the severest criticism.
Amongst these operations, which, to tell the whole truth, con-
stitute the essence of our art, the object of some is either to des-
troy the obstacles which oppose themselves to the free eruption
of the teeth, and to facilitate their regular arrangement, or to dis-
embarrass them of every thing which has a tendency to affect
their health or beauty ; the object of another class of operations
is either to furnish a remedy for the many alterations to which
these organs are subject, and which may cause their loss, or to
consummate, partially or entirely, this loss itself, when it is
demonstrated that their preservation can only be purchased at
the expense of the general health, or the injury of the adjoining
teeth.
In the chapter devoted to hygiene and orthopedia, we have
developed, in as full detail as was proper, in an elementary
260 OPERATIVE MEDICINE AND PROSTHESIS,
treatise, the rules according to which the first class of these
operations, such as cleansing and correcting irregularities of the
teeth, should be executed ; we will now turn to the second
class, which as they are resorted to only when actual disease is
present, constitute more legitimately, operative medicine ; such
zs, filing, cauterization, obliteration, luxation, excision, and, final-
ly extraction of the teeth, with all its consequences.
With regard to the question, which has been so often discuss-
ed as to whether it is absolutely indispensable that the surgeon
dentist, should be able to perform all operations with equal fa-
cility with both hands, that is, should be ambidextrous, it is our
opinion that every thing in relation to this subject should be re-
duced to this rule : although it is, no doubt, rationally possible
to demonstrate, in theory, that it is much more easy to operate
on the right side of the mouth with the left hand, and vice versa,
it should not be forgotten, that as persons naturally ambidextrous
are very rare, it is better, generally, to waive the advantages
ofiered by a more convenient position, than to run the risk of
operating with an uncertain and unsteady hand. Besides this,
there are operations which, for want of sufficient power, could
never be executed, except with the hand we use habitually, no
matter how much the other may have been exercised in particu-
lar cases.
Having disposed of this matter, we will now proceed, but not
after the example of most authors who have, heretofore, written
elementary treatises on our art : that is to give general rules,
simply, we shall enter into all the necessary details with regard
to each operation, and reduce the various steps to data sufficient-
ly exact, to enable the tyro to apprehend, at once, their spirit and
object, so that he will not be exposed to the risk of making
bungling and ineffective attempts, which will, invariably, cause
the patient to doubt his skill and experience, which, and these
may as readily be supposed, it is always desirable that he should
have.
But before commencing a description of the manipulations,
we will repeat what we have already said, that the dentist should
have the precaution to wash his hands, and that he should
plE^ce his patient in a good light, in an arm chair with a large
OR MECHANICAL DENTISTRY.
261
seat, with four feet, and of sufficient solidity to resist all the
movements of the patient, and the force of the operations. This
chair should be provided with strong arms, so that the patient
may, as it were, cling to them ; it should terminate, posteriorly,
by a back piece, the upper border of which should, in general,
be horizontal, but rounded and covered on the sides, so that the
head which, in most cases, rests upon it, may not be hurt.
As to a chair arranged either with fixtures to give the head
any desired inclination, the advantages of which have been so
much preached about, or a screw to raise and lower the head-
piece according to the height of the patient, we think that
although it may be useful it is not indispensable. The dentist
should, indeed, accustom himself to operate in chairs of all forms,
for, in case he should be called out of his office, he would find
himself much embarrassed if he had always operated in a chair
of a peculiar kind. Under such circumstances it should be suf-
ficient for him to place a pillow on the back of the arm chair, or
perhaps the simple chair, which is placed at his disposal.
We will also remark, that the dentist should not only have
immediately at hand all the instruments he will need, the prin-
cipal merit of which should consist in their being suitable and
strong, but he should avoid, as much as possible, making a dis-
play of them before his patients. This makes it necessary, in
our opinion, that he should keep them in the same apartment
where he operates, shut up in drawers, and arranged according
to the order in which they are used, that is to say, all the ex-
tracting instruments should be together, and in like manner, the
files, scaling and cauterizing instruments, etc. so that they can
be taken up promptly, and that the delay, which would occur if
it were necessary every time they were used to select such as
were wanted, may be avoided. It is almost unnecessary to say
that all the accessories of the instruments, such as the spittoon
towel, hot water, etc. should also be provided.
There is one thing which it is important to form a habit of
doing, that is to place yourself in the most convenient position
but it may be very readily seen that it would be difficult at the
outset, to establish any general rules for this purpose, as this
position must vary every moment, not only as regards the par-
262 OPERATIVE MEDICINE AND PROSTHESIS,
ticular operation itself, but also the various steps of each opera-
tion. All we can say about this matter, in general, is, that in
operating upon the upper jaw the operator is obliged to place
himself, standing, behind the patient, and in operating upon the
lower jaw, he, on the contrary, should place himself 6r/ore his
patient, with one knee on the floor, on the right or left side as
the case may be ; ordinarily, however, on the side opposite to
that on which the operation is performed. By placing the knee
upon the floor, the operator is brought more on a level with his
patient, his movements are made more conveniently, and it is
nuich more easy than if he kept himself in a bent position,
which would be necessary if he operated standing.
In most cases, the fingers are sufficient to hold the lips apart;
but quite often, in the cases of individuals, the muscles of whose
lips, especially those of the lower jaw, are endowed with great
contractile power, an apparatus, made to effect this object, should
be used. We have one constructed of platina; it is a species
of ovoid circle, hollowed out in its circumference, in the form
of a groove, which receives the lips, and keeps them forcibly
apart; it is arched so as to accommodate itself to the form of
the mouth.
The tongue, which is often troublesome, especially in the
course of prolonged operations, may be kept out of the way, by
means of a fixture, made of two semi-elliptical plates of box-
wood, ivory or platina, applied, one to the roof of the mouth, the
otlier placed upon the tongue, and kept apart by a piece of
whalebone, curved backwards, and fixed by each end into
sheaths made in the plates to receive them. The superior plate
is terminated by an appendage which touches the posterior bor-
der of the alveoli and the teeth, in order to make a projection
out of the mouth, by which the apparatus maybe removed with
facility and promptitude, in cases where it forms an obstacle
which cannot be immediately remedied by the fingers.
We admit, as will be seen, that the mouth upon which an
operation is to be performed, should be opened to a convenient
degree. In those cases, which, happily, are rare, where the
opening of the mouth is so small, owing to stiffness of the tcm-
poro-maxillary articulation, occasioned by certain chronic in-
OR MECHANICAL DENTISTRY.
263
flammations of the pharynx, by intense phlegmasia of the back
part of the mouth, especially when its seat is near the last mo-
lar tooth, it becomes necessary to effect the enlargement of this
opening. For this purpose, wedges of cork or wood are used,
the number and thickness of which are gradually increased. A
commencement is made with along thin wedge, which is pushed
between the dental arches, as far back as the coronoid process ;
this is removed after it has remained in its position for a day,
and is replaced by one of larger size; this is continued, from
day to day, till the perfect mobility of the jaw has been com-
pletely established.
It will be very readily supposed that a wedge of cork or
wood, placed between the dental arches, cannot be productive
of the desired result, except in cases of immobility arising from
accidental causes. Where the cheeks have become adherent to
the gums, before any attempt is made to separate the jaws, it
will be necessary to remove this obstacle, by destroying the
adhesion ; and, in true anchylosis, of the articulation, an opera-
tion becomes necessary, which belongs to general surgery.
But if the occlusion of the mouth has been produced by a cause
purely accidental, such as inflammation, it will always be pru-
dent to wait till this has disappeared under suitable treatment.
If the dentist should be called in, either to a person aff"ected
with tetanus, to whom it is necessary to administer remedies,
or to a person who has taken poison, and will not allow the ad-
ministration of the appropriate antidotes, or to a person who has
determined to starve himself to death, as has sometimes hap-
pened with lunatics of a certain kind, especially hypochondriacs,
he can do no better, if there is no breach in the dental arches^
than, with a chisel and mallet, to break away the two side teeth
above and below, and introduce into the opening, thus made, a
pair of forceps, the beaks of which separate as the handles are
brought together; by means of this instrument, the external
parts of the beaks of which are notched, to prevent them from
slipping, and a rack-work fixed to the handles, to keep them
firm at any point to which they may be brought together, the
mouth may be kept open as long as it is desirable. Having
been required, a few years since, to open the mouth of a young
264
OPERATIVE MEDICINE AND PROSTHESIS,
girl, who, in a moment of desperation, had swallowed acetate of
copper, we succeeded, with this instrument, so that the reme-
dies which her condition required, could be admitted.
Finally, with all the operations which the dentist is called
upon to perform in the mouth, after having invariably made an
examination, with sufficient care to avoid the commission of
error, and having informed the patient of the true condition of
of his teeth, he should act with promptitude but with safety ;
for, although it is important that he should do all that is neces-
sary, with sufficient rapidity to avoid the anxieties awakened by
delay, and to abridge the pain of the operation itself, it is indis-
pensable, also, that he should foresee all accidents which may
occur in consequence of too great precipitation, and those which
accrue to practitioners who, allowing themselves to be,alarmed
or intimidated by the cries of the patient, lose that coolness
which is necessary in order to act in accordance with the proper
methods, and which is so important in the crowd of excep-
tional circumstances that may occur unexpectedly, to complicate
the operation.
Sec. 1. Filing of the Teeth.
The file is an instrument in the most common use amongst
dentists. It was, undoubtedly, used in the earliest days of the
profession ; but it seems, nevertheless, to have been unknown
to Hippocrates, who, in speaking of ulcers of the tongue, says,
that "ulcers of the tongue are sometimes caused and maintained
by the roughness of a tooth," and makes no mention of the
file; but Galen, his commentator, attributes to himself its first
application to our art.*
This instrument is used in a great number of cases. Its ap-
plication, most ordinarily, is to remove decayed portions of the
teeth ; to bring down to a level with the others, a tooth which
is too long, and interferes with the perfect closure of the jaws,
or injures the opposite corresponding tooth ; to destroy asperities
produced by caries or fracture, incommoding or wounding the
* Hippocrates lived about four hundred years before, and Galen not until
two hundred years after, the Christian era.
OR MECHANICAL DENTISTRY. 266
tongue, the gums, the lips, or the cheeks ; and to prepare teeth,
or their roots, for the reception of artificial teeth.
The form of the file varies, necessarily, according to the pur-
pose for which it is used. Sometimes it is flat upon the sides,
and rounded or square at the extremity ; sometimes, on the
contrary, it is entirely round or triangular, or half-round, termi-
nating in a point. It is, generally, cut on both sides and edges,
and varies in size and thickness, according to the teeth for
which it is used ; finally, it is sometimes straight and some-
times curved. The cut is both simple and double; that which
is oblique produces less jarring, but cuts more slowly than that
which is cut twice across.
The file is generally fixed to a handle or file-carrier, when it
is used for the large molars ; but this addition is more disad-
vantageous than useful, when we wish to operate upon the front
teeth, for the reason that the file cannot be held so firmly as in
the fingers, and is more easily broken. The file-carrier may be
straight, but is very often curved, that is the portion in which
the file is fixed by a screw, is bent at a right angle with the
shaft; by means of this arrangement, the commissure of the
lips is avoided, a free field for the operation is obtained, and the
teeth upon which the operation is performed are more easily
seen.
The use of the file is subject to rules of two species. Some
are applicable to the generality of cases, others relate to the spe-
cial end which is to be accomplished. In general, the patient
should be seated on a firm chair, in a good light; the operator
should hold the instrument between the thumb and fore-finger
of the right hand ; from time to time, he should take the pre-
caution to dip his file in tepid water; this greatly facilitates the
action of the file, and, in the winter time, prevents the disagreea-
ble sensation which is always produced by a cold body coming
in contact with the teeth. The operator should be careful to
hold firmly, with his left hand, the teeth he files, in order to
avoid loosening them, and to prevent all vibration. In cases
where he has occasion to operate upon loose and painful teeth
of the lower jaw, he should not, as has been advised by Maury
and other writers, attach them to the adjoining teeth, no matter
34
266 OPERATIVE MliDICINE AND PROSTHESIS,
how firm these may be; but he should support them, in the
course of the operation, by a ligature, held on the inside of tlie
mouth by the fore-finger of the left hand. We do not approve
of the precaution which most dentists seem to regard as so neces-
sary, that is, to rinse the mouth after each stroke of the file, for
the purpose of getting rid of the calcareous particles removed
from the tooth by the file ; for we regard this enamelled dust
as an agent which not only assists the action of the file, but
renders it less rough and unpleasant.
In filing a tooth for any cause, care should be taken to pro-
tect those adjoining, and also the healthy parts of that upon
which the operation is performed ; for this purpose, files should
be obtained, of various size and form, cut on three sides only,
that is, on one side and both edges ; the safe side should be
placed against the tooth which it is desirable to spare. There
is another precaution which it is indispensable to observe : the
part of the file which is not brought into service should be
covered with linen, in order to save the commissures of the
lips ; this is especially necessary when the teeth in the back
part of the mouth are operated upon, and the file-carrier is dis-
pensed with.
In order to perform the various operations upon the teeth
which are accomplished by means of the file, this instrument
should be made of fine, well tempered steel ; the teeth of the
instrument should be sharp and cut regularly, for if they are
irregular and widely separated, the shock they produce, when
used, is painful and often insupportable to the patient. In some
cases, an operation commenced with one file, is completed with
another; the dentist should, therefore, have at hand a number,
of various sizes and forms, and also several file-carriers, both
straight and curved, so that he may be able to select any which
accidentally become necessary. When the teeth are very hard,
it sometimes becomes necessary, in order to obtain more power,
particularly when the molars are the subjects of the operation,
to fix the fragment of a file, protected by a piece of linen or pa-
per, in a pair of forceps. It is in such cases as these, particu-
larly, that the file should not be cleaned during the operation,
as the detritus augments its action.
OR MECHANICAL DENTISTRY. 267
Guided by these general rules, the dentist, if he finds it ne-
cessary to operate upon the back teeth of the upper jaw, places
himself behind and on the right side of his j^atient, if the teeth
to be operated upon are on this side, and on the left if the
contrary is the case ; he inclines the head in the opposite direc-
tion, uses the fore-finger of the left hand to raise the lip, and, in
order to obtain more power, grasps the file with his whole hand.
If, however, the front teeth are operated upon, the head is
simply inclined backward, and the file is held, according to cir-
cumstances, with the whole hand, or with three fingers only,
after the manner we shall presently describe.
If the lower teeth are to be operated upon, the dentist places
himself, on the contrary, in front of the patient, depresses the
lip with the fore and middle fingers, the thumb always taking
a solid point of support under the chin ; the process is then the
same as that followed in the upper jaw. When the front teeth
of the lower jaw are operated upon, the head should be inclined
slightly forward.
Let us now examine into the various cases which require the
use of the file ; but first establishing, as an invariable precept,
that the file should always be used gently and lightly, every
thing like a jerking movement being carefully avoided ; the
operation will always have been performed with sufficient
rapidity, if it is accompUshed without loosening the teeth and
irritating their vital parts.
1, The most common of all circumstances in which the file*
is used, is in the commencement of caries. If this has affected
one of the sides of a tooth, a careful exan)ination should be
made to ascertain whether it has been communicated to the ad-
joining tooth; and, to ascertain this with certainty, the two
teeth should be separated. If the adjoining tooth is discovered
to be perfectly sound, a file, cutting on one side only, should
be employed to remove the decay from the affected tooth ; in
using the file for this purpose, if the affected tooth is in front
and above, it should be supported by applying the thumb upon
the gum; the movements of the instrument should always be
made with great regularity. If both adjoining teeth should be
found affected, a file cut on both sides and both edges should
be used.
268 OPKRATIVE MRDTCINE AND PROSTHESIS,
Tf the decay is superficial, it, should be entirely removed -, if
it be not painful, the file should be used rather too much than
too little. Let us speak more explicitly : if the caries have not,
for instance, destroyed more than one-fourth of the tooth, it
should be filed parallel to its longest diameter, until the decay-
ed cavity is entirely removed, and the surface of the tooth found
to be perfectly smooth ; it must not be forgotten, however, that
the filing should be done, as much as possible, at the expense
of the internal face of the tooth, so that the portion which is
apparent may be spared. But if the decay has extended more
deeply than one-fourth the tooth, it is our opinion that, to
remove this, it is imprudent to file away the healthy bone above
and below the decayed portion. In doing this, a space is made
which is almost equivalent to the loss of the tooth ; it would
have been well if this had been thought of by M. Lefoulon,
who gives the dangerous advice, in relation to this subject, to
destroy a third, or even one-half of the tooth.* In cases where
the decay has penetrated more deeply, it is necessary, after
having, of course, isolated the affected tooth, to use a half-
round file, in order to reach directly the decayed part, and avoid
filing the tooth in its whole length. If, however, after having
effaced this cavity, the bone of the tooth at this part still remains
black,*and the bony part is sufficiently thick to permit the re-
moval of this portion, without reaching the dental canal, the
file should be used until the spot is effaced. But, if the caries
bas penetrated the tooth as far as the canal, it will simply be ne-
cessary to separate it from the adjoining one, file the decayed
part as much as possible without weakening the tooth too much,
and then, after detaching, carefully, all the soft, blackish parts,
to cauterize, and, if the pain do not prevent, to plug it.
All authors recommend, besides, as an important rule, that
when a tooth is filed on the side, o. portion near the gum should
be left untouched, that is, a shoulder of bone should be allowed
to remain, in order that the space made may not close up again,
which would, otherwise, infallibly be the case. This precept
is erroneous, and for two reasons : the front teeth, which seem
* Ouvrage cite, p. 245.
OR MECHANICAL DENTISTRY.
269
particularly to be the subjects of this rule, have, in general, the
form of a pyramid, the base of which is toward the crown, and
the apex toward the root, so that the line separating the portion
filed away from that which is to remain, even if one-third were
removed, would almost always fall outside of the neck ; and,
secondly, even admitting that enough has been removed from
the tooth to approach the point of contact with the alveolus, it
would certainly be much better to take measures to bring the
separated teeth together again, as a space in the dental arch,
especially in front, is always unsightly, and interferes with the
pronunciation. We have often been called upon to make sub-
stitutes for teeth which had been filed in this manner, so as to
leave remaining only a half or a third of their substance, pro-
ducing a deformity so very unpleasant and inconvenient, that
the persons proposed sacrificing them entirely. The precept,
therefore, cannot be carried into practice, and, even if it could,
it would lead to injurious consequences.
The use of the file, for the removal of caries from the lateral
surfaces of the incisor and canine teeth, requires the greatest
care. Used imprudently, it may occasion great loss of sub-
stance, by removing the sound and healthy with the diseased
portion, and however oblique the direction given to it may be,
it is always liable to act upon the whole surface of the tooth,
without removing all the caries, thus foiling to remove the dis-
ease, and to accomplish the end proposed by the operation. To
obviate this inconvenience, files bent in form of an arch, ara
sometimes used, and also rose-head drills, a species of file,
which can be brought to bear directly upon the principal seat
of the caries.
Until lately the drills were simply fixed at the end of a long
slender shaft, and rotated rapidly by means of the fingers or
by means of a drill-bow. But in this last case, fixed invariably
to the end of the shaft upon which works the drill-bow, it
can only be brought to bear upon the anterior surface of the
front teeth. Some years ago it was believed that an inven-
tion had been made which brought to perfection the apparatus
upon which these drills were fixed, by arranging them in such
a manner that they could be either fixed directly at the end of
270 OPERATIVE MEDICINE AND PROSTHESIS,
the principal shaft or obliquely to it; in this second direction
the drill receives its rotatory motion through the principal shaft
by means of two cog-wheels, which work at an angle with each
other. One of these wheels is set in the principal shaft, and
the other in the secondary shaft which receives the drill. Im-
planting this secondary shaft on either side of the principal cog-
wheel two different combinations are obtained, so that, by this
arrangement, the caries, in both its diverse positions, may be
reached. In one of these positions, the drill acts precisely as
when placed at the end of the simple shaft; in the other posi-
tion, it inclines toward the hand of the operator in such a man-
ner that it is brought to bear directly upon the internal surfaces
of the canine and incisor teeth.
Without denying that this is a very ingenious instrument, we
persist in preferring the common drills, particularly those which
are fixed at the end of a straight- handle, and are rotated by the
fingers ; there is scarcely any situation in which the caries can-
not be reached with this instrument, and it has the advantages
of being entirely under the control of the hand, and of being
less complicated, and less formidable to the patient.
Instead of having recourse to the file, some dentists prefer
scraping out the decayed part with excavators, curved into vari-
ous forms, and well tempered. By means of these instruments
they cut away as much of the tooth as they deem necessary,
from the inner part, preserving the external plate of the enamel.
This method may have the advantage of attacking the decayed
portion more directly ; but, whatever M. Delabarre may urge in
its favor, it has the objection of increasing the cavity, thus
favoring the accumulation of alimentary substances and saliva,
if it is not plugged, whilst the file, which in most cases tends
to level the surfaces, removes with certainty the decay, by
means of the loss of substance which it ordinarily effects in the
parts in the middle of which the cavity was situated.
2nd. Finally, when it is necessary to have recourse to the
file for the purpose of levelling teeth which are too long, prepar-
ing roots for the reception of artificial teeth or removing promi-
nences of roots, which wound the adjacent parts, half round,
triangular, or flat files, according to the case, are used. If the
OR MECHANICAL DENTISTRY. 271
situation prevents the use of the file transversely, it should be
directed obliquely, thus cuttingaway the desired portion in parts
and in various directions. Care should also be taken to avoid
filing in an equal and uniform manner, as the operation will be
rendered by this means, more protracted and painful ; little
prominences, should, as much as possible, be formed, because
these enable the file to act more effectually ; large portions are
cut away and the operation performed more promptly.
This method of shortening the teeth can be resorted to in
those cases only when they exceed the others in length but very
little ; but, in cases of quite common occurrence when the pro-
jection is very considerable, as often occurs with those which
have lost their antagonists, or when we wish to remove the entire
crown, in order to substitute for it an artificial one, the following
process should be followed. The tooth to be operated upon
should be held, firmly, between the thumb and finger till a fur-
row can be filed as close to the gum as possible, on both sides
of the neck, and in front, the edges of a pair of cutting forceps
should then be placed in the furrow, and the tooth excised by a
steady and firm pressure. The furrow, which we have directed
to be made previously to using the cutting forceps, has a two-
fold advantage, it assists the cutting action of the forceps, pre-
vents them from slipping, and the tooth from cracking, as will
hereafter be seen. When the file approaches the centre of the
tooth, pain of the most insupportable kind is often produced ; if
the situation of the tooth permits, it is necessary, then, to file
from the opposite side as near as possible to the centre. If the
pain is so great as to prevent the completion of the operation
with the file, the remaining portion should be cut away by
means of the forceps, the nerve cauterized, and the asperities of
the root cut down with a fine file.
Before performing the operation for reducing a tooth in length,
it is necessary to ascertain whether the dental pulp will be
reached ; in young subjects great caution should be observed to
guard against this disaster, for the pulp is then of considerable
size, and cannot, without great inconvenience, support the ope-
ration of filing. For this reason, recourse should not be had to
this operation without it is absolutely necessary. It is some-
272 OI'ERATIVK AIKUICINE AND PHOSTilESlS,
times important to file the milk teeth, when decayed, in order to
preserve them, and some dentists, amongst others, Fauchard,
have seen infants with teeth so large, a short time after their
birth, that it has been indispensable to file down their points,
because they wounded the breast of the nurse. Some practi-
tioners are of the opinion that in this latter case it would be bet-
ter to wean the infant or to extract the precocious tooth. We
are not of this opinion, for the weaning of an infant is too serious
a matter to be admissible when it can be avoided,* and the ex-
traction of a tooth at this age may cause the loss or removal
of the germ of the secondary tooth which is, at this time, in
close connexion with that which precedes it. M. Oudet has
communicated to the Academy, a case in which, in extracting a
small molar for an infant, the follicle of the secondary bicuspid,
which was situated loosely among its roots, was also brought
away; it was already covered with the external tubercle of its
crown. t For the reason it has been established, as a general
rule, that the first teeth should never be extracted till those of
the second set are ossified and situated in distinct sockets. If
called in to a case of the kind, to which we have above alluded,
we should not hesitate to file or even excise the offending
tooth.
Whatever may be the cause for which it is found necessary to
perform the operation of filing, and whatever may be the skill of
the dentist and the quality of his files, it often occurs that he is
not able to complete the operation at a single sitting, without
great discomforts to his patient, such as setting the teeth on edge,
local pain and at the same time a general irritation which mani-
fests itself by a nervous agitation and a buzzing sensation in the
head. This, however, should not be sufficient to cause him to
give up the performance of the operation, but it is well, under such
circumstances, to defer it and accomplish in several sittings what
cannot be done at once, and it should never be forgotten that
*0q this subject, the premature weaning of an infant, we find a very in-
genious letter of Professor Trousseau in llie February number of llie Jour-
nal dc Medicine, for 1843.
fSee the Bulletins de V Jlcademic Royale de Medicine.
OR MECHANICAL DENTISTRY. 273
in such cases, as in all others, no trace of the passage of the file
should be left. To effect this, after a rapidly cutting file, finer
ones should be used, until the filed surface, as nearly as possi-
ble, presents its primitive smoothness. We think, however, the
advice given by M. Begin,* and many other surgeons, may ba
dispensed with ; that is, to rub the filed parts with a piece of
hard smooth wood, so as in a manner to burnish it and restore
the polish of the enamel and bony portion.
It sometimes occurs in the course of the operation, that the file
gets fixed between the teeth ; it is best then to stop and gently
disengage the instruments, for in getting it out too hastily there
is a risk of breaking away portions of the enamel. This is an
accident, too, which occurs sometimes with dentists whose hand
has not yet acquired, by practice, the necessary steadiness and
firmness.
Such are the general circumstances, under which the teeth
are filed, and the rules according to which this operation should
be practised. Performed with skill at the proper time, it oflfers
precious remedy, too often neglected, of preserving the teeth
from decay and arresting its progress after it has commenced,
and also to restore their natural solidity to such teeth as have
been loosened in consequence of their disproportionate length ;
but when it is performed without discernment, and in disregard
of the indications, which we have pointed out, its consequences
are grievous and become an infallible cause of ruin to the parts
to which it has been applied. That this is true, daily observa-
tion, unfortunately, proves.
Sec. 2 — Cauterization of the Teeth.
Applied to dental surgery, the object of the operation of cau-
terization, is to destroy the nerve and the pulp, for the purpose
of appeasing obstinate tooth-ache ; of drying momentarily caries
more or less deep, of a sanious character, to arrest alveolar haem-
orrhage, and to prevent the reproduction of fungous tumors,
springing from the bottom of the alveoli, or from the surface of
the gums. ^
* Diciionraire de Medicine et Chentrgie Pratiques, <. 6, p. 197.
274 OPERATIVE MEDICINE ANli PROSTHKSIS,
This operation is generally performed in two ways, with a
heated instrument, or with caustics. The former which con-
stitutes the actual cautery is that which is most generally prac-
tised ; in some cases, however, its application is not sufficient
to relieve pain, and it is sometimes observed to augment it, when
the case is such that it cannot be conveniently applied. The
same remark holds good with regard to its use against caries,
although it is often effective in arresting its progress and drying
it up; at other times, in consequence of its disorganizing action, it
renders the affected teeth more brittle and lessens the chance of
their durability. Nevertheless the promptitude and energy with
which it acts, compensates, most generally, for its inconve-
nience, and cause it to be regarded, with good reason, as a reme-
dy which, in certain circumstances, is of great value.
Applied for the cure of odontalgia, the actual cautery has been
recommended by Hippocrates ; but as is very properly remarked,
by M. Duval, it is not certainly known whether in imitation of the
Egyptians, he advised its application to the tooth itself or to the
gums or temples, as is supposed by Professor Alpin ;* or whether
he employed it as the Japanese who, according to Ten-Rhyne,t
cauterized the nerve at the mental foramen.
Whatever may have been the opinion of Hippocrates, with
regard to this subject, the destruction of the dental nerve by the
actual cautery is effected by means of an instrument of the fol-
lowing description, heated to a white red : the cauterizing in-
strument is a simple steel stylet about two or three inches in
length, with an oval enlargement some eight or ten lines from
its extremity, to retain the caloric in order to prevent it from
growing cold too rapidly ; it is fixed in a handle. Some den-
tists prefer to have this bulb movable so that it may be adjusted
to suit every variety of case ; but we think it better that this
bulb should make one with the shaft of the instrument, as its
caloric will then be more rapidly communicated. If fixed, the
best distance seems to be about an inch from the extremity of
the shaft, so that the portion of the instrument, which is imme-
* De MediciMi JEgypiiorum, lib. 3, cap. 12.
t Dissertatie de .Brthride el Mantissa Schetnatica de Jlcvpunclura.
OR MECHANICAL DENTISTRY. 275
diately applied, may have sufficient length to answer in every
possible case ; as, for instance, when it is used to cauterize the
branch of the artery at the bottom of an alveolus, to arrest haem-
orrhage. For ourself we prefer, for this purpose, a simple iron
wire bent upon itself, which, in consequence of flexibility, is
not liable to break in the dental canal in consequence of the
sudden movements which patients sometimes make, under the
pain attendant upon the operation. As to the bulb we regard
it as useless ; as the operation is very painful and it should be
performed with all possible rapidity, and the simple instrument,
properly heated, will always contain enough caloric to effect the
intended purpose.
If one of the incisors or canine teeth of the lower jaw is to be
cauterized, the operator places himself on the right side and a
little in front of the patient ; he separates the lips with the index
and middle finger of the left hand, and supports the jaw with
his thumb placed under the chin ; then holding the heated in-
strument, in this case curved, in his right hand, he introduces
it with rapidity deeply into the dental canal, makes with it two
or three rotary movements and withdraws it. If one of the
small molars is to be cauterized, the operator places himself on
the same side with the tooth, which is to be the subject of the
operation, the lips, as in the former case, are to beseparate^ by
means of the index and middle finger; but the thumb is now
placed under the angle of the jaw ; the operation is then per-
formed in the manner just described. Some dentists, in order to
protect the lips and tongue from injury, make use of a species of
large spatula, adapted especially to^this purpose, but this instru-
ment seems to us to be useless, as in all cases where any thing
of the kind is necessary, the handle of the small mirror, used
in the mouth, answers quite well, as a substitute. It is to be
observed, here, however, that, as the small molars have two roots,
it is indispensably necessary to pass the instrument down into
both. As to the large molars, they are never destined to receive
pivots, and, as they are provided with three or four roots, it is
difficult to reach the nerve in all of them, they are, therefore,
cauterized with an instrument enlarged at the extremity suf-
ficiently to destroy at once the whole body of the pulp in the
crown.
27G OPERATIVE MEDICINE AND PROSTHESIS,
The application of the actual cautery to the teeth of the supe-
rior jaw differs, somewhat, from the process just described. The
operator places himself in front, and a little on one side, raising
the superior lip with the index finger of the left hand, the thnmb
resting upon the teeth in the vicinity ; the lower lip is depressed
by means of the middle finger of the right hand ; the instru-
ment, which should be straight and not curved, as it is when
used for the lower teeth, is guided by the index finger and
the thumb.
Thus far we have considered cauterization only in its appli-
cation for the purpose of destroying the dental pulp; when re-
course is had to this extreme remedy for the purpose of arresting
the progress of a deep caries a different process is adopted.
The asperities of the edges of the cavity are first removed by
means of the file or cutting forceps ; then with an instrument
slightly curved, and cutting at its extremity, or which answers
a better purpose, a curved scraper, al.l the soft parts should be
removed from the cavity, which must be dried out with a lock
of cotton; the cauterizing instrument is then introduced with
caution and touched against the diseased part; in order to burn
it to a proper depth, the instrument, according to the extent of
the caries, and the sensibility of the tooth, should be introduced
into the cavity two or even three times.
The instruments used for this purpose, are not of the same
character as those intended for cauterizing the nerve, but are
species of pluggers formed of a metallic shaft more or less curv-
ed, at the extremity, which has generally an oval form, and
is furnished with a surface which gives a place of support to the
finger, so as to allow it to be pressed firmly. It is useful in this
species of cauterizing instrument, to have it provided with a bulb,
which we condemned in the stylet for destroying the nerve, for,
in the case for which this is used, it is necessary that the heat
should be retained longer. It may be remarked, here, that the
hand by which the instrument is held, should be protected by a
towel. We give the preference to cauterizing instruments such
as we have just described, to those fixed in a handle, because
they are firmer and because the cement, which fixes the latter
in the handle, is melted by the heat.
OR MECHANICAL DENTISTRY. 277
These instruments sometimes used to arrest humid erosions
of a certain character, which resemble an efflorescence of the
enamel ; but in such cases they act only in drying, not cauter-
izing, the diseased portion ; to accomplish this object, the instru-
ment when heated red is brought near, without touching the
enamel, but if it be brought so near as to touch, it should be but
slightly heated, and brought in contact with the enamel several
times, as it is necessary to use great caution to avoid the disas-
ter of causing the substance to crack.
Cauterizing instruments are generally heated in a small fur-
nace, when they are large ; in a candle, or, what is better still, in
the flame of a spirit lamp, when they are small.
But, however cautious we may be in counteracting these
preparations, there are many persons, and especially females,
who cannot make up their minds to allow a red hot instrument
to be applied to their teeth. In such cases, recourse must be
had to caustics, (potential cautery.) These caustics are either
solid or liquid. The nitrate of silver, combined in equal pro-
portions, with the acetate of lead, and caustic potash, form the
first class. This species of caustics is used by introducing
into the cavity of the tooth, by means of a large slender pair of
spring forceps, a very small portion, which is covered with cot-
ton and allowed to remain till the desired effect is produced,
when it is removed. The liquid caustics are, in general, am-
monia, the nitric and sulphuric acids, and also the butter, or
chlorine of antimony, which, in consequence of its oleaginous
nature, belongs rather to the liquids than the solids ; a small
lock of cotton is touched to the caustic, introduced with a
stylet, and covered with cotton or a little wax.
A dentist of Nancy, M. Turck, has proposed a very ingeni-
ous method for the use of concentrated acids, in cauterizing the
teeth. This is a small glass tube, about one-third of an inch
in diameter, with one of the extremities terminating in a bulb
and the other in a capillary tube. When the bulb at one
extremity is held in the hand, the air which is contained in it
expands, and a portion is expelled ; the capillary extremity is
then inserted into the acid, which is to be used, and as soon as
the air in the tube, becoming cold, contracts, a vacuum forms,
278 OPERATIVE MKDICINE AND PROSTHESIS,
which is filled by the acid. When the instrument is thus
charged, the extremity is applied to the point to be cauterized,
the bulb is held in the hand, and as the air becomes again
heated and expands, the liquid is forced out.
This, we repeat, is a very ingenious instrument, but it has two
great objections : in the first place, it is too fi-agile, and is, there-
fore, liable to be broken in the mouth of the patient, by some of
the sudden movements which are instinctively made when
pain is experienced ; and, besides, it may be readily supposed
that it would be impossible to make any calculation of the ex-
act quantity of acid which would be forced out; consequently,
far from adopting the opinion of M. Malgaigne,* who speaks of
it as the most certain method of cauterizing the teeth of the
lower jaw, we regard it rather as an amusing philosophical toy,
than an instrument occupying an important rank amongst
those the assistance of which We should rationally invoke.
The dangers to which not only the osseous tissues of the
teeth to which these caustics are applied, but also the parts ad-
jacent to them, which it is difficult to protect, should render the
operator very circumspect in their use ; perhaps it would be
well to discard them entirely. Besides, it is very inconvenient
to apply them to the teeth of the upper jaw, from which they
have always a tendency to escape, in consequence of their
gravity, no matter how favorable the cavities in which they are
placed may be. Another unpleasant result which we have ob-
served to follow the use of caustics is, that when they fail en-
tirely to destroy the dental pulp, it becomes the seat of fungous
tumors, which may put on a cancerous character.
We think that the cauterization of the teeth, either by means
of the actual or potential cautery, is an extreme remedy, espe-
pecially when it is resorted to for the purpose of destroying the
sensibility of a painful tooth. Many dentists, with reason,
maintain that it is better, at first, to attempt the accomplishment
of this object by the use of the essential oils, or concentrated
alcoholic tinctures, such as those of cinnamon, mint and cloves,
to which may be added ether, balsam of tolu, extract of opium,
* Manuel de Medicine Operatoire, page 108.
OR MRCHANICAL DENTISTRY. 279
myrrh, incense, and many other substances, of the efficacy of
which we have spoken, explained the mode of action, and de-
veloped the various methods of apphcation, in the pathological
part of this work, especially in the portion devoted to caries.
Sec. 3. — The Obliteration or Plugging* of the Teeth.
We have seen that the operations of filing and cauterization
of the teeth had each its peculiar advantages, and had, for their
common object, the arrest of the progress of caries. But, from
a very little reflection upon the methods of practising these ope-
rations, it will be seen that, far from obviating the effects of ca-
ries, they only raider these effects more apparent, for, no matter
how skilfully they may be executed, they always augment the
amount of lost substance of the affected tooth. It is not sur-
prising, then, that a desire should have existed to obliterate the
cavity which these operations cannot efface, as much for the
purpose of preventing the lodgment and retention, in it, of food
and saliva, and the action of the atmosphere, as to restore to the
teeth their natural usefulness.
Under the generic expression of plugging, the operation
having for its object this obliteration, is designated. For this
purpose, lead, in leaves, was formerly exclusively used, for
which has now been substituted, tin, silver, gold and platina,
which is used, like the lead, in leaves ; and, lately, a compound,
known by the name of the inventor, as Darcet's mineral, of
which we will presently speak more fully. We will notice, also,
the various attempts which have lately been made to effect the
object proposed by the operation, in the most convenient
manner
The time at which this operation was first practiced, as also
the name of the person who first performed it, is not known.
Some erudite persons have given Celsus that honor; but what
this author says with regard to the operation, proves, simply,
that he advised the filling of a decayed tooth with lead, in order
*The French word used to designate this operation, and which wc have
not thoug-ht proper to translate literally, is plombage, (pleading.) T.
2S0 OPERATIVE MEDICINE AND PROSTHESIS,
to enable it to bear the pressure necessary to effect its extrac-
tion, and not for the purpose of accomphshing what is generally
proposed at the present day. The following is a literal transla-
tion of the expressions he makes use of :. "But if the tooth is
much decayed, it is necessary, first, to fill the cavity with lint
or lead, well packed in, so that it will not break under the
forceps."*
The best conditions in which a cavity, requiring plugging,
can be, is not only to be free from pain, but insensible to the
action of heat and cold, to the contact of hard bodies, and the
pressure of particles of food ; it is better that it should not be the
seat of a discharge of any kind, and the cavity should be suffi-
ciently anfractuous to retain the metal after if% inserted, as this
would soon escape from a cavity shaped like a funnel, with the
base looking towards the crown, especially if the tooth were
situated in the upper jaw. These three fundamental condi-
tions, insensibility of the tooth, absence of any discharge, and
anfractuosity of the cavity, are not absolutely essential ; for we
daily succeed in relieving odontalgia, by the obliteration of the
cavity which is the seat of pain, thus preventing the contact of
the air, the saliva, and particles of food ; in putting a stop to a
discharge, by arresting the work of disorganization, which is
the cause of it; and, finally, in cases where the cavity is not of
a suitable form to retain the metal used, we make it so with the
proper instruments.
Maury has committed a great error in laying down, as a gene-
ral rule,t that a tooth should be plugged '■hvhenever it is decayed
or painful ;^^ for there are cases in which it would be impossi-
ble for the patient to bear the slightest pressure in the painful
cavity, and, if this is the case, how much more difficult would
it be to bear the introduction of a foreign body. If Maury has
committed an error in setting down this general rule, M. Mal-
gaigne is not nearer the truth, when he gives the following
directly opposite advice :J ^'■Painful teeth should never be plug-
* Jlc si exesus est (dens') ante id foramen vel linamento vcl bene accummo-
dato plombo replendum est, ne sub forcipe confriugaulur. De re medica,
liber vii, caput iii, sectio v.
tOuvrage cite, p. 249.
I Manuel de Medicine Operatoire, p. 109.
OR MECHANICAL DENTISTKY.
281
ged. Both are wrong not to etsablish at tlie same time the rule
and the exception, as there is danger by expressing themselves
in such unqualified terms to lead beginners into an injurious
practice. M. Malgaigne, vainly rests for support upon the opin-
ion of Duval, who expresses himself, with regard to this sub-
ject, as follows : "^s a general rule a tooth should never be plug-
ged except when it is entirely free from pnin and insensible to
pressure of any kifid ;^^ it is not on account of this opinion, the
less demonstrated, that a great number of persons only cease to
suffer pain from their teeth when the decayed parts have been
protected from the action of the atmosphere, the pressure of
particles of food, &c.
All attempts to plug a tooth should be preceded by an exami-
nation sufficiently careful to enable the dentist to obtain an ex-
act knowledge of its vital and physical condition. For this
purpose a sound is used ; this is a species of simple metallic
shaft, generally straight, but sometimes curved. When it is
found, after this examination, that nothing contra-indicates the
operation, (that is, we repeat, when the cavity is not so tender
as to give room to believe that it would be unable to bear the
pressure of a foreign body, and the pressure necessary to effect
its introduction, and when the opening of the cavity is not larg-
er than its interior is, or can be made,) it is to be cleaned out
in accordance with the rules we have described; then, after
having dried it out by the successive introduction of pledgets
of cotton, an effort should be made to form some asperities ca-
pable of readily retaining the metal. We would observe here
that, in the mouths of some individuals when we are operatin*
upon the lower jaw, the saliva flows in such abundance that it
completely fills the cavity, the moment the cotton which is
used to dry it out, is removed, and consequently prevents the
operation, for dryness of the cavity of decay is indispensable.
In cases where it is impossible to operate with sufficient rapidity
to avoid this obstacle, the lips and gums should be covered with
a layer of cotton which will absorb the saliva as rapidly as it
presents itself.
After having taken these preliminary steps, let us suppose the
operator is about to make use of any of the metals, in the form
36
282 OPERATIVE MEDICINE AND PROSTHESIS,
of leaves ; a portion of one of these should be torn off and
rolled between the fingers, so as to bear some proportion to the
cavity to be stopped, but always larger. Putting himself in a
convenient position, he places the finger of his left hand at the
opening of the cavity, whilst, with a small sized, blunt pointed
plugger, he forces in the metal. Then taking an instrument
of larger size he again presses upon the metal, brings it to bear
upon ail points, in a manner perfectly to fill the cavity ; finally,
after having removed all the inequalities it may present around
the circumference of the cavity, it is polished with a burnisher.
Although a matter of pure detail, it will be well to observe,
here, that it is better to take rather^more than less of the metal
necessary to fill the cavity, so that new portions will not have
to be added to that first introduced, for these always adhere
with difficulty. Sometimes, however, it is a good practice to
pierce the whole filling in the centre, for the purpose of adding
a small portion, which, on being forced in, acts upon that first
introduced, in the manner of a wedge. As to the advice given
by some dentists, as an undeviating rule, when the cavity
is in the grinding surface of the crown, to raise the plug above
the edge of the cavity, so that it may be forced down in the act
of mastication, we formally disapprove of it, because the opera-
tion of plugging should be performed by the dentist himself,
and it is ridiculous to depend upon an unequal pressure, to
complete it, which it often does to the detriment of the corres-
pondent tooth, upon which is imposed this task.
Simple good sense will indicate that it is quite difficult to per-
form this operation when the decay is situated between teeth
locked closely together, when that cavity is on the posterior
surface of a large molar near to another tooth, and so far back
that the commissure of the lips prevents the free use of instru-
ments ; it may be accomplished, however, with the aid of skill
and patience, and by repeated attempts, after it has been separa-
ted from the adjoining tooth, by means of the file.
The fear of exerting a pressure upon the nerve, which would
be productive of pain, has induced M. Delabarre to advise the
application of a little concave plate of gold to the bottom of the
cavity, before the metal is mtroduced, so that the filling may
OR MECHANICAL DENTISTRY. 283
rest upon it as upon a floor. This precaution appears to us to
be at least a superfluous complication, for, if the little plate used,
is thick, it fills the cavity too much, and adapts itself badly to
the bottom, and if it is there, it yields to the pressure and fails
entirely to effect the purpose in view.
The process we have described is applicable to all the metals
which are used in leaves ; but it is not a matter of indifference
which of these metals is used for the purpose of plugging de-
cayed teeth. Lead, which was formerly, almost exclusively,
used, is almost entirely abandoned now, because it soon oxydi-
zes, and, consequently, quickly becoming black, it imparts this
hue to the teeth filled with it ; silver has the same objection.
Tin, platina, and still better, gold, are now used in preference
to any other metals ; * gold answers particularly well for filling
cavities near the anterior part of the mouth, not only because it
is not liable to oxydize, but because its color approaches nearer
to that of the teeth than any other metal. But the metallic
compound, which is known as Darcet's mineral, is more used
at the present day than any of the metals which we have named.
It is composed of eight parts of bismuth, five of lead, and three
of tin, and this compound is rendered more fusible by the addi-
tion of a tenth of mercury; but this addition, to say the least,
we regard as useless, first, because the preparation compounded
according to M. Darcet's receipt is sufficiently fusible, and be
cause the mercury has the effect of turning black sets of artifi-
cial teeth in the mouth, as, also, the teeth which are filled with it.
This metallic compound has the immense advantage of fu-
sing at a temperature below 100 degrees, (Centigrade ;) it is not
used in leaves, as the other metals we have mentioned, but in
little ingots. It is used in the following manner: after having
cleaned out and dried with cotton, the cavity to be filled, so
that no humidity is left, which, dilating under the influence of
the caloric, would prevent the metal from running into all the
anfractuosities of the cavity. Some pieces of the metal, more
* Some modern dentists have claimed ibr themselves the merit of having
first used gold for filling teeth ; but this is not true, for Fauchard formally
makes mention of this metal. See his third edition of 1785, tome 2, p. 68.
284 OPRRATIVK MKOICIVF AND PROSTH F.SIS,
than sufficient to fill it, are put into the cavity ; the cauterizing
instrument is then held in the flame of a candle, or lamp, till it
receives heat enough to be felt when the finger is brought close
to it; it is then applied to the metal, which immediately melts
and runs into all the sinuosities of the excavation, where it is
pressed lightly in every direction, by the finger, until it hardens ;
then it is polished with the cauterizing instrument whilst it
still remains warm. This metal, as will be readily perceived,
accommodates itself better than any other to the different forms
of the dental cavities; it is only to be regretted that its grey
metallic color contrasts with the natural color of the teeth, that
it can only be used for the lower teeth, and particularly when
the cavities are upon the grinding surfaces of the larger molars;
besides these objections there are many persons who cannot be
made sensible of its manner of fusion, and who become alarmed
at the necessary preparation of heating the instrument, expect-
ing it to produce pain, which we will say, en passant^ is fre-
quently quite acute.
It is desirable then to find a mastic which combines the ad-
vantage of the color, durability, and solidity of the metals
which are preferred. Did the ancients know of any substance
combining these several conditions? Of this we are entirely
ignorant, and, in spite of all our researches, we have discovered
nothing upon which Laforgue bases his assertion,* that this
substance exists in 'many of the insular colonies of the Pacific
Ocean, among the savages of Canada, and the Bedouins of Africa.
The species of cements with an aluminebase recently proposed
by some members of our profession, are far from attaining the
desired end, as we have already observed ; they can hardly be
used, except in cases where it is desirable to ascertain by a pre-
paratory operation, whether the presence of a foreign body will
produce pain in a decayed tooth, or will renew that which has
been suspended.
It was for the purpose of attaining this end, that M. Taveauf
has proposed to fill the tooth, temporarily, with a little cotton,
* Semeiohgie Buccale el Buccamancie, p. 83.
t See the Gazelle des Hdpiiaux, of the 2d and 5th of May, 1840.
OR MECHANICAL DENTISTRY.
285
dipped in a solution of resin of the pistacAa lentiscus, or simply
in benzoin, dissolved in alcohol at forty-two degrees. This
substance, prepared in the manner here directed, would serve
equally as a palliative remedy, such as opium, camphor, myrrh,
&c., which it may be desirable to retain in the bottom of the
cavity for a time, and it can be removed at pleasure. A cement,
very similar in character, has been recommended by M. O.
Henry, who gave the following directions for its preparation :
Make a saturated solution of mastic in tears, in sulphuric ether,
and decant it after it has macerated several days ; it is used by
dipping into it a little pledget of cotton, equal in size to the
decayed cavity ; the cotton immediately agglutinates, and fills
the cavity.*
We have, for a long time, indulged the hope of discovering
a substance of greater hardness than those of which we have
been speaking. We have principally devoted our efforts to the
Jluates, which, as is known, have the property of hardening
when exposed to humidity; but, up to the present time at least,
they have not come up to our expectations ; the great obstacle
is the variable nature of the salivary and buccal fluids, which,
from alkaline become so promptly acid, and vice versa. The
following compound shows, however, we were, at least, in the
right track : equal parts of siliciate or fluate of lime and alumine,
dried and pulverized, with a sufficient quantity of water to form
it into a homogeneous paste ; this is introduced into the cavity,
and its desiccation^^favored by the approach of a heated instru-
ment.
M. Taveau has also proposed, for the permanent plugging of
teeth, a substance which he calls silver paste, and which another
dentist has attempted to bring into general use, under the very
insignificant title of mineral succedaneum. This preparation is
made by saturating virgin silver, reduced to a very fine powder
and well refined, with a given quantity of mercury ; this com-
pound is ground in a mortar, until the metals are well incorpo-
rated with each other, when it is pressed in a piece of kid skin
deprived of its epidermis, for the purpose of extracting as much
* Foy : Formulaire Med. Prat., 4th edition, p. 184.
286 OPERATIVE MEDICINE AND PROSTHESIS,
as possible of the mercury, which escapes from the skin in little
drops. The residue obtained is a paste sufficiently firm, but
also quite manageable ; it may be kept, for use, in a glass bottle,
stopped with emery.
"This preparation," says M. Taveau, "is used cold, and is
introduced into the cavity of the tooth with a plugging instru-
ment, precisely in the same manner as the metals in leaves.
The mercury volatilizes, in consequence of the heat of the
mouth, and, in the short space of three or four days, the silver
remains in a single piece, which fills all the anfractuosities of
the cavity as perfectly as if it had been melted and poured into
it." This new method of plugging teeth, in the opinion of the
inventor, has a great superiority over most of those which are
commonly used at the present time ; because it does not require
the employment of heat, as is the case with Darcet's mineral ;
because it adapts itself better to the irregularities of the bottom
of the cavity than the metals used in leaves; and, finally, be-
cause, as it does not harden immediately, it can be removed if
it is discovered, after being introduced, that the tooth was not
in a condition to be plugged permanently.
This substance, to give to it its real value, and judge of it
without prejudice, has these objections : it is of a dull grey
color, which presents a very disagreeable aspect ; it communi-
cates to the tooth filled with it a blackish hue, which renders it
entirely unfit for the front teeth, and, in consequence of the
evaporation of the mercury, which always continues, even after
it has acquired its greatest hardness, exerts an injurious influ-
ence upon any artificial teeth contained in the mouth ; an ob-
jection which we have also urged against Darcet's mineral.
The objection last mentioned seems to be well founded, from
the fact which we have observed, that persons employed in
manufactories where mercury is used, wearing artificial teeth,
find it necessary to have them frequently repaired. The ob-
jections, we have stated above, may be urged against the fusible
metal which is generally employed; but one property of this
paste, if it do not altogether proscribe it, should, at least, circum-
scribe its use ; it is this : if the tooth should become painful
after this substance has perfectly hardened, the removal of the
filling requires very painful', and often useless efforts.
OR MECHANICAL DENTISTRY. 287
When a tooth is well plugged, it is absolutely impossible for
the saliva or air to penetrate the material with which the cavity
is filled, and the tooth may, consequently, be preserved for a
long time without undergoing any change. But no matter with
how much care and skill the operation may have been performed
it is by no means certain that the pain which accompanied the
formation of the cavity may not return ; and it often does return
with much acuteness, and is sometimes followed by inflamma-
tion and abscess. In many cases such results are successfully
combatted, and the unpleasant symptoms made to disappear
permanently, but very often, also, it becomes necessary to
remove the filling from the tooth and to leave it in this condi-
tion until all signs of irritation have passed away, and no dis-
charge from the cavity remains. A second attempt should then
be made to plug it, but the precaution should be observed to
press so lightly upon the metal that it may be removed in case
it become necessary, without much difficulty ; this is effected
by means of a common excavator, when the cavity has been
filled with any of the metals in leaves, and with a heated cau-
terizing instrument of Darcet's mineral, have been used.
The unfavorable results which sometimes follow this operation,
has induced some practitioners to give the advice, never to plug
a tooth, at once permanently. Instead of doing so, they advise
the operator, at first, to press the gold only hard enough to exclude
food and moisture, and, after some days have elapsed, to press it
more firmly, and when the sensibility of the tooth has entirely
passed away, to empty the cavity, and refill it perfectly. This
precaution may answer very well for tyros, but the experienced
practitioner will generally know, at once, upon examining a tooth,
whether any unfavorable results will follow a permanent opera-
tion, and will not find it necessary to adopt this temporary fill-
ing as a general rule.
Finally, in cases where a decayed tooth is so very sensitive
as to be unable to bear the pressure of a hard body, but which
is injured by contact with the air, and particles of food, we
would simply advise the cavity to be filled every day with cot-
ton, which may be saturated with cologne, or something of that
nature, if the sensibility of the tooth should not prevent it; but
28S OPERATIVK MEDICINE AND PROSTHESIS,
at some subsequent period recourse should be had to a perma-
nent operation.
Sec. 3. — Luxation of the Teeth,
By the luxation of a tooth is to be understood its displace-
ment from its natural situation, by drawing or moving it suffi-
ciently to rupture the vessels and nerves which penetrate the
central cavity, at the extremity of the roots, without removing
it entirely from its socket. After it is thus displaced it is forced
back into its original position, by means of suitable pressure upon
the crown.
This operation, one of the most painful of those common to
dental surgery, was formerly very frequently performed for the
arrest of very superficial caries, and to give relief in cases where
a tooth was painful without being externally diseased. Some
contended that the luxation need not be complete, whilst others
maintained the contrary ; all however were agreed upon this
point, that the end proposed by the operation was only attained
when the nervo-vascular chord, which penetrates the tooth, was
ruptured. Dentists who are familiar with all the circumstances
attendant upon the operation of the extraction of a tooth will be
aware that they should always so control their efforts as to stop
at a given point, and to ascertain with certainty when the den-
tal chord is broken ; it is necessary, as Laforgue * has very pro-
perly remarked, to more than two-thirds to luxate a tooth, that is
to move it upon its axis till an acute angle of sixty degrees with
the edge of the alveolus is formed.
Now, in such case, one of two things may happen, either the
tooth will be completely removed from its socket, which, of
course, is more than was designed to be accomplished, or the
desired rupture of the vessels and nerves has been incomplete ;
when this occurs, inflammation and pain of such a character
ensue as to render the extraction of the affected tooth necessary,
and to cause regret that it had not been done at once.
But admitting that the sweeping movement given to the tooth
* Th£oric et Pratique de VAnt du DentiHe, p. 121.
OR MECHANICAL DENTISTRY. 289
is guarded enough to avoid its complete extraction, and quite
sufficient to rupture the dental chord, it is not always certain
that the alveolar process may not be fractured. On the contra-
ry, as will be seen in the following paragraph, fracture occurs
in the majority of cases, and the fragments produced by it, how-
ever small they may be, invariably cause irritation and inflam-
mation of the gums, and the alveolo-dental periosteum, the tooth
is finally pushed out of the socket and is lost after causing
symptoms, of which pain is the least to be regarded, especially
in a numerous class of patients, who have gums spungy and
liable to bleed.
It is observed, besides, that in almost all cases where the
teeth grow firm again, after this operation, that a fistula between
the neck and the gum is formed, through which pus, produced
by the parts contained within the alveolus, is discharged ; and
even when in young and healthy subjects, they recover their
firmness without leaving any traces of their luxation, in the
course of three, or at most, five years, no longer receiving the
fluids which give them vitality, they lose their color and present
an appearance almost as disagreeable as would result from their
entire loss.
For these reasons we do not hesitate to declare formally, that
luxation, resorted to as a means of preserving a diseased or ir-
regular tooth, is too doubtful in its results, in the present con-
dition of the service, to be classed among the regular operations.
We do not even make an exception in favor of the incisor and
canine teeth, the loss of which is so much to be deplored, and
for a still stronger reason, the small molars, which, however,
Maury pretends to have luxated without any other inconveni-
ence than a little sensibility. This author in saying * that the
force given to the instrument during the performance of this
operation, should be very light, in order to lacerate, in the least
possible degree, the vessels and nerves distributed to the toothy
would seem to show that he was not aware of the object for
which this operation is proposed ; to rupture the vessels, and in
this manner to extinguish entirely the sensibility of the tooth >
* Ouvrage cite, p. 257 .
37
290 OPERATIVE MEDICINE AND PROSTHESIS,
and in advising the operator to fracture the edge of the alveolus
as little as possible, he himself pronounces condemnation upon
an operation of which he proposes to be the defender.
We presume none will regard as contradictory what we have
here said, and the advice we gave in our pathological part to
endeavor to maintain in their places, and preserve from external
violence, such teeth as have been accidentally loosened or lux-
ated : in such cases an absolute necessity exists which forces
the dentist to disregard no means of restoring such teeth.
Sec. 5. — Excision of the Teeth.
The excision or amputation of a tooth is the complete section
of its crown. Recourse is had to this operation in a canine or
incisor tooth, when the crown is impaired and it is desirable to
preserve the root, for the purpose of preventing the adjoining
teeth from approaching each other, which, as we have already
shown, would be the case if the roots were removed — to receive
the pivot of an artificial tooth, or to furnish a support for an
apparatus of any kind whatever. This operation is sometimes
effected without the aid of a dentist: that is, by the action of
the jaws upon such hard substance getting between them, in
cases where the teeth are very much decayed. In such case
nothing more remains to be done, but to file down the remain-
ing portion of the crown, so that the gum will cover the bases
of the artificial teeth. This operation should never be attempted
before the age of eighteen or twenty, because, till then, the
dental canal has not become sufficiently narrow to prevent the
easy entrance of air and food, the contact of which might have
the effect of irritating the nerve and the central pulp.
The instruments necessary for the performance of this opera-
tion are a saw, a file, and a pair of strong cutting forceps. The
file and the saw have the common inconvenience of producing
an unpleasant jarring and a setting of the teeth on edge. The
saws, which are used, should be fixed in a curved carrier by
their two extremities, in such a manner that they can be used
in a perpendicular direction or at right angles. They may be
obtained so small as to be scarcely the thickness of a sheet of
OR MECHANICAL DENTISTRY. 291
paper and not more than a line in width ; they can of course be
passed between teeth situated very closely together.
When it can be done, the saw should be insinuated into the
space where it is to act, and so fixed in the carrier that when
it reaches the neck of the tooth it can be turned so as to cut
across ; this can generally be done with ease, as the space is
always greater at that part. If the blade cannot be passed
between the teeth, it should be taken from the carrier, and after
passing one end, with the cutting edge turned from the gum,
between the affected teeth, at the neck, it is again mounted in
the mouth. But this is rarely necessary, for when it becomes
important to sacrifice the crown of a tooth, little hesitation will
be felt about removing so much of it as will open a way for the
saw.
When the file is used in the excision of the teeth, it hardly
serves any other purpose than that of making a horizontal
groove, near the neck, to assist the action of the cutting instru-
ment, which plays the principal part in this operation. This
instrument, generally, is a pair of strong cutting forceps, either
straight or curved, with the jaws concave, so as to embrace the
neck of the tooth to be excised ; the handles are sufficiently
long, and strong, to exercise a pressure capable of removing the
crown, without causing it to crack. Common observation de-
monstrates that a living tooth is cut off more easily, with less
crushing, than a dead one ; the juices, with which it is supplied,
renders its tissue more elastic, and, consequently, less brittle.
The facility with which this operation may be performed,
when the forceps are well constructed, some years since, in-
duced many dentists, among others an English practitioner, *
to substitute it in almost all cases, where extraction was thought
necessary, as a means of relieving pain. The fact upon which
they founded this practice, is, that in at least eighty-four, out of
an hundred, cases, of tooth-ache, the pain is situated in the
* This practitioner, is Mr. Fay, of American origin. The pamphlet, in
which he has developed the advantages of this method, compared w^ith the
result of extraction, was printed at London, in 1827, under the title of "A
Description of the Mode of Using the Forceps, Invented for the Extrac-
tion and Excision of Teeth."
29i OPKRATIVE MEDICINE AND PROSTHESIS,
crown, and not in the root; and the advantages which they at-
tribute to this operation, over that of extraction, is, that it is
less painful, and, that the roots are not only preserved, so as to
furnish a base for artificial teeth, but their presence prevents the
absorption of the alveolar process, which would take place if
they were removed, and the consequent displacement, loss of
the teeth, and sinking in of the cheeks.
The excision of the teeth for the cure of tooth-ache, has not,
by any means, met with general approbation; because, say its
opponents, as the nerve is not entirely destroyed, the impres-
sion of the air, the slightest sensations of heat, or cold, the con-
tact of any foreign body, whatever, suffice to produce pain of
a very violent character. To this objection, we reply, that
such inconvenience is very easily avoided, by making it an
invariable rule to follow the excision, by the cauterization of
the nerve, particularly, as we have already remarked, in pa-
tients who have not passed the thirtieth year. Our personal
experience has convinced us, that, although some English
practitioners have exaggerated the advantages of this remedy ;
the French dentists, on the other hand, have neglected it too
much, and, that, if its application were better studied, it might
be found of much value.
There is, however, another objection to be urged against the
excision of teeth, as a general practice, which is, that when the
desired object is accomplished, one of the principal aids in
extraction is removed, for it cannot be denied, whatever some
practitioners may say, that the extraction of a root is, in most
cases, more difficult than that of a tooth, whose crown is
entire. For this reason it is quite necessary that those who
desire to substitute the excision of teeth for their extraction,
should carefully examine them to ascertain whether the disease,
for which the crown is removed, has not extended into the root
or roots. This may always be feared when the pains occasion-
ed in a tooth, by caries, has been accompanied by a discharge,
and particularly, alveolar abscess, for, in such case, it is probable
that the root, or its coverings, are diseased ; when the decay is
too trifling to account for the pain which is suffered, it may be
suspected that there is exostosis of the root or alveolus, or some
affection of that nature.
OR MECHANICAL DENTISTRY. 293
Finally, there are persons for whom it would be advantageous
to substitute excision for extraction ; we allude to those persons
whose teeth, previously extracted, we have reason to believe,
from the examination of teeth, or other indications, have roots,
which, by their extraordinay divergence, or convergence, would
render their extraction difficult and dangerous.
Sec. 6. — Of the Extraction of the Teeth.
Of all the remedies for diseases of the teeth, there is none
which have been practiced so long ago as their extraction ; for,
not only is it spoken of in formal terms, by Hippocrates, who,
also, attempts to correct the abuses to which it might lead, but,
a passage in Cicero, designates Esculapius, the third of that
name, as the person by whom it was first proposed. *
In one of the preceding chapters, whilst describing the
causes, and the deficient characters, and treatment of diseases of
the teeth, we pointed out most of the pathological circumstances
which authorize their extraction, and render it essential ; but
there are other circumstances, not noticed, which are of import-
ance to the dentist, who desires to practice his art conscientious-
ly. To be contented by saying, with a modern author,t that
teeth should be extracted, "in all cases in which the caries has
penetrated to the pulp cavity, and it has become sensible to
impressions of cold, or heat ; and that mastication causes them to
be painful," we are inclined to think, is generalizing rather too
much, is throwing doubt upon the utility of the operations which
we have described in the previous portions of the work, and is ex-
posing the teeth to a destructive vandalism ; on the other hand,
it is, we think, disregarding the necessity of extracting teeth
perfectly healthy in themselves, but which exert an injurious
influence upon the adjacent parts, of which we have presented
cases, in treating of absorption of the alveoli. | Indeed, the
* Tertins, (^Esculaphis,) — qui primus purgationem alvi deMis que evulsio-
nem, vtferiunt, invenit. De Natura deorum, lib. 3.
t Maury; ouvrage cite, p. 260.
I Of all the authors who have written on our art, Bunon has best estab-
lished the grounds of the occasional necessity of the extraction of a sound
tooth. This necessity he has demonstrated by a great number of cases.
294 OPERATIVE IMEDTCINE AND PROSTHESIS,
presence of any one of the indications laid down in the above
general rule, is not sufficient to justify the extraction of a tooth,
and where they are all present together, it is not always
authorized. Thus, to preserve a tooth deeply decayed, it is
often only necessary to cauterize or scrape it, in order to
arrest the progress of decay, and afterwards to plug it, in order to
protect it from impressions of heat and cold, and, finally, to re-
move, with the file, such asperities as would interfere with mas-
tication. But even if the indications for extraction do exist,
should we not defer its performance, in such case, for instance,
as the following : when the affected tooth is buried in suppurat-
ing tissues — when the patient is a prey to another malady, upon
which the shock of the operation might have a bad effect — when
patients are so nervous, that the simple preparations alone for
the operation, would produce very serious symptoms ; this is
very often the case with women and children of the higher
classes.
The extraction of a tooth, then, which is, unfortunately, re-
garded with indifference by most persons, is an operation which
should be performed, by the dentist, jealous of the public good
and his own reputation, only in the last extremity, that is, when
there exists an absolute necessity, and in cases where the fear
that a tooth may become the cause of deformity, demands its
removal, the reasons upon which this necessity is established,
are deduced, generally, much less from the physical alteration of
the tooth, and the pain to which it is subject, than from the
persistence of this pain.
In making up a decision in this matter, how much prudence
and attention is necessary, in order to avoid the commission of
error ! A tooth should never be extracted until the operator is
The most remarkable of these is that of the Marechal de Saxe, whom he
could only relieve of a habitually recurring tumefaction of the cheek, by
extracting, in opposition to the opinion of the most celebrated practitioners
of his time, a perfectly sound tooth; the alveolus of this tooth, however,
was destroyed to such an extent, as to form, exteriorly, a pouch into which
a blunt sound could be introduced. See his work, entitled "Experiences et
Demonstrations pour servir de suite et de prcuves d VEssai sur les Maladies des
Dents, I vol. in 12, 1764.
OR MECHANICAL UENTiSTRY. 295
positively assured that it is either the seat or the cause of the
pain; he should not always regard the directions of the patient,
for it is very often the case that some tooth, other than the one
which is pointed out, is the cause of the trouble. Two adjoin-
ing teeth, equally decayed, may both ache at the same time;
one only may be really painful, and the disease may be in one
in which the decay is hidden, as well as in that in which it is
apparent. Sometimes, indeed, it has been observed that the
extraction of a perfectly sound tooth has afforded temporary
relief from pain, which was caused by a diseased tooth in the
vicinity. Garengeot relates a case of this nature.* It is often
the case that the patient does not know the seat of the pain, or
it is in the jaw opposite to that which they indicate. Very lately,
a young lady called upon us to request the extraction of the
first left small molar of the inferior jaw, whilst it was quite evi-
dent to us, by the color of the swelling about the same tooth in
the upper jaw, that this was the true seat of the pain she was
suffering. We had great difficulty in persuading her that this
was the case, and we did not succeed in convincing her, till we
introduced an instrument into the cavity of the upper tooth; this
revived the pain, which had ceased for a moment, and she was
satisfied. Finally, it is often the case that the pain is not con-
fined to any particular tooth, or to any number of teeth, but ex-
tends to all parts of the mouth supplied by the dental nerves, so
that it is altogether impossible to fix upon one tooth more than
another. We refer the reader to what we have said with regard
to dental neuralgia, in a former part of this work, in which the
pain, although felt in the teeth, is caused by some disorder of
the dental nerve, and extraction, in such case, would afford
no relief.
The operation of extraction should never be performed until
the dentist has ascertained, with certainty, the diseased tooth ;
if a shadow of doubt remains, no effort should be unemployed,
which can tend to dissipate it. After the patient has pointed
out the tooth which he supposes to be the seat of pain, it should
be examined with the eye or small mirror, to ascertain the ex-
* JYoveau Traite des Instruments dc Chir, tome 2, p. 66.
296 OPERATIVE MEDICINE AND PROSTHESIS,
tent of the decay, and then moved slightly with the thumb and
finger; if tiiis should not excite pain, it should be struck with
a hard body, such as a plugging instrument; cold water should
be taken into the mouth, and brought in contact with it ; or
another means should be employed, which, thongh more pain-
ful, is still more certain : the cavity should be explored by a
small instrument, the use of which, as in the case to which we
have above alluded, is sufficient, generally, to furnish a certain
indication of the condition of the tooth.
It is certainly a very important step to have ascertained the
diseased tooth, but it should still be borne in mind, that, no
matter how much prudence and skill may be called into requi-
sition, and whatever may be the instruments used, this opera
tion is alway painful. A skilful dentist should even be able,
on the first inspection of the tooth to be extracted, to judge of
the degree of difficulty he will encounter, and the intensity of
the pain which will be produced. If the tooth is so much de-
cayed that it cannot be expected to bear the pressure of the ex-
tracting instrument — if the crown is so small as to indicate that
the roots are long and divergent — if the patient is of an exces-
sively nervous temperament — if the tooth is surrounded by
inflamed and painful tissues — these unfavorable circumstances
should be considered, and the patient informed, with as much
address as possible, of their existence, and the probable result,
so that, in the event of complete failure, or of incomplete suc-
cess, he may not blame you for lack of foresight, nor accuse
you of want of skill.
As this operation, except in the eyes of those who delude
themselves, is one of manual dexterity, it must not be believed
that pathological and anatomical knowledge can supply the
want of a practiced hand; the contrary, indeed, is daily evinced,
by the success, even in the most difficult cases, of empirics or
the most ignorant dentists ; it is, therefore, of great importance
that the dentist should accustom himself to the use of all instru-
ments for the purpose, to become familiar with their various
forms, to ascertain with exactness their mode of action, and to
become enabled to distinguish, promptly, those cases which
require the application of one kind in preference to others.
OR MECHANICAL DENTISTRY. 297
With children, especially, is this judgment and pronnptitude
necessary, for every unsuccessful attempt frightens them, and
prevents them from submitting to a new attempt; it is, besides,
important to use all possible address to prevent them from seeing
any thing which will excite their alarm. The solicitations of
parents very frequently produce an effect the very opposite of
that which they anticipate. Fox, with much reason, has said,
"It is better to say nothing to the child about your intention to
perform the operation, up to the moment when it is effected;
in wishing to prepare it, the imagination is excited with dread,
and at the decisive moment he loses courage."
From this minute but indispensable detail of the precautions
which should precede this operation, we pass on to the exami-
nation of the instruments used, attaching much less importance
to their formation, than to the true methods of using them, and
the precautions by which their use should be guarded.
Of the Instruments generally used for the Extractioii of the
Teeth.
If we have been obliged to see that dental caries is an affec-
tion against which almost the entire materia medica has been
directed, we are now constrained to declare that there is no sur-
gical operation, for the performance of which so many instru-
ments have been invented, as that which is at present under
consideration. From the forceps, which, according to Erasis-
tratus, were deposited in the temple of Apollo, dovi^-n to those
which Hippocrates advised to be used, and from the last down
to those we use at the present day, this instrument has under-
gone the most singular changes in form ; and, although the
number of new inventions have considerably diminished, espe-
cially of late years, they are still sufficiently numerous to form
a curious collection. But, whatever may be their formation,
they all act as levers, the object of which is to separate the teeth
from the jaws, by making use of an effort which overcomes the
resistance offered by these organs upon the alveolar processes,
or rather the force of adhesion which maintains them united to
the entire alveoh. But what is a lever? This it is important
38
298 OPERATIVE MEDICINE AND PROSTHESIS,
to know, in order to appreciate the manner in which these
instruments act, and to turn each to the best account. This
piece of knowledge will serve, too, to enable the reader to appre-
ciate the various combinations which furnish the basis of the
dental prosthesis.
A lever is what we call a shaft, or inflexible bar, straight or
curved, by means of which one power, aided by a fulcrum, en-
deavors to equilibrate, to sustain or overcome a weight or re-
sistance placed upon a third point of its length. There are four
things essentially distinct, to be observed in all species of levers :
1st. The resistance, which is the load we wish to raise, or the
body we desire to extract ; 2d. The power, or force we use to
overcome the resistance; 3d. The fulcrum, which is the fixed
point upon which the lever moves; 4th. The arms of the lever,
which are the portions of the shaft, equal or unequal, comprised
between the fulcrum and the resistance or the power, or between
these two. The relative disposition of these four parts consti-
tutes three distinct orders of lever.
The first order is, that in which the fulcrum is situated be-
tween the resistance and the power, and from this cause has
been named the inier-mohile ; of this order, the balance and the
scissors are examples. In the second order, the resistance is
found between the fulcrum and the power, and is called the
wter-resistant^ as the cfowbar- In the third class, the power is
between the resistance and the fulcrum, as in the vice ; this has
been called inter-puissant.
The force of the power and the resistance, as well as the
space traversed by the points to which they are applied, is in
direct proportion to the length of the arms of the lever. Thus,
if the arms are of equal length, and the same degree of force be
applied to both extremities, the power and the resistance are
equal, that is, they are reciprocally equilibrated. If the forces
are unequal, the equilibrium is destroyed ; but the movement
which results from this inequality of force is precisely the same
for the points of resistance and power. Finally, when the arms
of the lever are unequal, the power acts with as much more
energy, and traverse, proportionally to the resistance, a space as
much greater as the arm of the lever towards its side is larger
OR MECHANICAL DENTISTRY. 299
than that of the side of the resistance, and vice versa. For
instance, if the arm of the power is twice as long as that of the
resistance, the force being equal, the power will act with double
the degree of energy, and, in order to neutralize the forces, or
to produce equilibrium, will require the resistance should be
double its weight.
We will conclude by saying that, of the three orders of lever,
the second or inter-resistant, is most favorable to overcome great
resistance; next comes the first, or inter-mobile; as to the third
order, it is most unfavorable of all, the power acting between
the fulcrum and resistance, which prevents it from being used
with advantage when the resistance is greater than the power.
We will now apply these physical laws to the description and
methods of using the instruments appropriated, at the present
day, to the extraction of the teeth.
The number of instruments, as we have said, was formerly
immense, but has now diminished to some seven or eight.
Some practitioners, indeed, and among them we take pride in
classing ourselves, or to whom, for a long time, we have set an
example, have the good sense not only to give the preference to
those instruments whose mechanism is most simple, but to
make use of some three or four exclusively, which they endea-
vor to apply appropriately, and to handle skilfully. For this
reason, the tirtoir, a species of hawks-bill forceps, the inferior
portion of the beak of which is flat, and rests upon the gum,
whilst the superior, mounted upon this by a screw, is directed
by the thumb, and, passing behind the tooth, answers the
purpose of the hook of the key; the pelican, a sort of key, with
all the objections, without any of the advantages which are sup-
posed to attach to the latter — the poussoir and its masse de plomb,
etc., are generally, and very properly, discarded. Hardly any
others are now retained, but the ke]/ of Garengeot, the simple
lever, (elevator,) the pied- de- lie he, the langue-de-carpe, the for-
ceps, the straight or curved davier, (hawks-bill forceps,) and,
finally, the pelican, which some practitioners persist in using.
We will now give a summary description of them, without en-
tering into details, which would be altogether useless to those
who have never seen and handled them, and superfluous to
300 OPEKATIVE MEDICINE AND PROSTHESIS,
Students who have frequented a dentist's office, which is the
only means of becoming a good practitioner.
1. The key of Garengeot is a complicated instrument; it is
composed of a mov^eable hook, articulated transversely upon a
smooth, somewhat quadrilateral body, called the bolster, which
is placed at the extremity of a shaft of steel ; this shaft is termi-
nated, at the other extremity, by a handle, which is fixed trans-
versely, and which is grasped by the hand of the operator. As
will be seen, this instrument forms a lever of the first order;
the hook seizes the tooth which is the resistance, the bolster
rests upon the alveolus, opposite to the point where the hook
catches, and, at the other extremity of the shaft, where the
handle is fixed, is the power, which is the hand of the operator.
This instrument, which is more used than any other, is of very
ingenious construction, for there is no tooth or root which may
not be removed by means of it. But the question, whether it
is as easy for the patient as for the operator, arises here ; and
candor compels us to answer this question in the negative.
Whatever, indeed, may be its conformation, it always com-
presses, forcibly, between the hook and bolster, the tooth and
opposite alveolar process, covered by the gum ; and, in conse-
quence of the circular motion which it causes the tooth to de-
scribe, in the direction of the movement given to the handle,
the extent of which is in proportion to the length of the root, a
pressing apart of the walls of the socket cannot be avoided.
Now, in the first case, one of two things occurs, either the hook
and the bolster are placed entirely above the neck of the tooth
and the edge of the alveolus, when the operation fails entirely,
or the tooth breaks : or else it is applied lower down, the tooth
is more firmly grasped, but, even in the beginning, compressing
the alveolus and lacerating the gum. In the second case, the
roots, in making a circular motion, almost always fractures the
socket, and carries away a portion of the gum, as is seen by
every practitioner daily. Many persons imagine that they may
divest the key of some of its disadvantages, by raising the
instrument more than it is rotated ; but that this is an error, the
most simple examination serves to demonstrate ; indeed, the
very first step in the process is to fix the instrument solidly, by
OR MECHANICAL DENTISTRY.
301
turning the handle, and thus bringing the hook towards the ful-
crum. If you attempt to extract the part thus seized by ele-
vating it, you reduce the key to the character of a simple for-
ceps, with, however, these disadvantages, when compared with
that instrument : a loss of power, in consequence of the
two angles which are formed by the hand in relation to the
handle and the hook to the shaft; and with less convenience,
because you make use of the instrument in a horizontal direc-
tion, while you use the forceps in a straight line.
We know well that it will be replied that when a root is to
be extracted, the key does most excellent service, for, however
slightly the extremity of the hook is pushed down or up, ac-
cording as the root is situated in the lower or upper jaw ; but
then it is evident that the piece of alveolus between the hook
and the root will fly away as the root is extracted. This objec-
tion cannot be overcome in any way, for if the extremity of the
hook is kept above the edge of the alveolus, the pressure of the
fulcrum upon the opposite side of the alveolus is liable to pro-
duce fracture in that part. The precaution should always be
observed to separate the alveolus from the portion of gum which
covers it ; for, without this is done, the gum is always certain
to share the fate of the alveolus, and be torn away with it.
The disadvantages of the key are so very evident, that there
is not a practitioner of any reputation, from Jourdain, (1790,)
down to Messieurs Delabarre and Maury, who have not felt the
necessity of submitting it to some modifications. Some have
bent the shaft near the bolster, and this seems to be one of the
most important modifications ; others have carried the bolster
before or behind the hook, a modification which renders the
instrument liable to loosen an adjoining tooth ; and others
finally, have believed that, by substituting hooks bent at almost
a right angle, for those of a semicircular form, a better hold
will be taken of the crown, upon which the latter are liable to
slip. Two things, however, have caused us great surprise : the
first is, that no one, before ourselves, should have thought of
disembarrassing the extremity of the shaft of the screw, which
adds to its length, and of placing the hook directly on a level
with the shaft, so that there would be no obstacle in the way of
302 OPERATIVK MRDTCINF AND PROSTHESIS,
applying it directly to the wisdom teeth, for the extraction of
which they seem particularly appropriate ; the second is, that
practitioners who have used the key habitually, should have
been so long in discovering the advantages of a round bolster,
which permits the hook to take any desirable direction. Maury
is very evidently deluding himself when he believes that he is
the originator of the improvement consisting in the removal of
the bolster, so that when the hook is applied, for the extraction
of the third molar, that part of the instrument rests against
another tooth. This credit belongs to an English practitioner,
as is clearly proved by the following sentence from Fox: "Mr.
Spence, in placing the hook beyond the bolster or fulcrum, has
overcome all these difficulties ; because, by resting the bolster
against the external side of the second molar, the hook is car-
ried to the inner side of the third molar, which may be removed
without the least risk." We regard this modification as an im-
provement only in relation to the difficulty which is often ex-
perienced in bringing the ordinary bolster to bear upon the ex-
ternal face of the wisdom teeth ; in all other cases, we regard it
as dangerous to make a fulcrum of any other tooth than the one
we wish to extract, because the force proper to the bolster and that
inherent in the power, no longer counterbalancing each other,
the tooth which furnishes a support for the first may be pushed
in, whilst the other is forced outward; the only qualifying cir-
cumstances in the case is in the relative firmness of the teeth to
be extracted, which can never be determined a priori, and that
which results from the distance which separates them from the
power; this, however, in any case, is of little consequence.
The most of these corrections and modifications, we repeat,
have not obviated the vices which flow naturally from the mode
of action of the key, and have been proposed, we are forced to
say, more, perhaps, in a spirit of self-love, than from a convic-
tion that they were real improvements. For ourself, we have,
for a long time, almost entirely renounced the use of this instru-
ment, confining it exclusively to cases of teeth which there is
reason to believe have strong roots, and which offer a good
hold ; and, even then, we only use it to luxate them ; it may,
therefore, be readily imagined how much we were astonished
OR MECHANICAL DENTISTRY. 303
to find a modern author maintain,* that "the key of Garengeot
is, beyond contradiction, superior to all other instruments :" and
more particularly when this author pretends to extract teeth not
only without effort and without producing pain, but with cer-
tainty and with pleasurable sensation, (tuto et jucunde. ) Such
are the expressions of which he makes use !
M. Duval is far from sharing this predilection for the key, for,
many years ago, he said, with regard to this matter: "Let no
one believe that I am an advocate for the use of the key of
Garengeot, as I have not made use of it twice in two hundred
operations.! M. Duval, however, may flatter himself with hav-
ing been the author of one of the most valuable improvements
which this instrument has ever undergone, that of making the
fulcrum movable, so that, in consequence of its articulation with
the shaft, it exercises a uniform pressure upon the gums, during
all the steps of the operation of extraction. It is proper to ob-
serve here, that those surgeons, (some dentists, however, who,
perhaps because they are ignorant of the proper use of better
instruments, recommend the key,) who have taken the trouble
to acquaint themselves perfectly with the mode of action of the
key, do not pretend to deny that it generally causes fracture of
the alveolus^ but are contented with declaring that skill, in the
use of the instrument, simply '■'■consists in causing the slightest
possible fracture of the socket.''^*
But for those persons who desire to learn, as we have done,
by experience, the disadvantages of the key, we will describe
the manner in which it should be used. As for all other opera-
tions in the mouth, the first step should be to place the patient
in a good light; a hook should then be selected, of such size
that its curvature will be proportioned to the volume of the
tooth, (this is important, for, if the hook be too large, there is
danger of taking away parts of the alveolus where the point
touches, and if too small, there is, on the other hand, great
danger of breaking the tooth,) it should be fixed in its place sa
* Lefoulon : ouvrage cite, p. 303,
] Journal de Med. Chir. et Pharm. de Sedillot, Janvier, 1814.
f Malgaigne : ouvrage cite, p. 1 12.
304 OPERATIVE MEDICINE AND PROSTHESIS,
that when the key is held horizontally the handle will be to-
ward the breast, and the bolster looking upward, the hook will
fall over upon it from left to right, if it is about to be used for
the extraction of a tooth on the right side of the lower jaw, or the
left side of the upper jaw, and vice versa^ if the tooth is situated
in the left side of the lower jaw, or the right side of the upper.
The bolster should then be well wrapped with a strip of linen,
or, which will answer the same purpose, a pledget of cotton, a
piece of sponge, or caoutchouc of sufficient thickness should
be placed upon the gum, where this part of the instrument is
to rest. The operator places himself behind the patient, if the
tooth to be extracted is in the upper jaw, directing him to throw
the head back ; if the tooth is in the lower jaw, he places him-
self before the patient and fixes the head straight. Then,
holding the handle of the instrument firmly in the palm of the
right hand, he extends his fore-finger to the hook, which he
throws back from the fulcrum and holds motionless ; he then
applies the hook under the neck of the tooth, almost always on
the iimer side, and as near as possible to the edge of the alveo-
lus, (but never on the gum at the part corresponding to the
middle part of the root, as recommended by M. Begin,) * and
fixes it in this position with the fore-finger of the left hand ;
then rotating the instrument slightly outwards, he grasps the
tooth in such a manner that the whole of the crown is lodged
in the curvature of the hook, and on the opposite side, the po-
sition of the bolster corresponds to the upper extremity of the
root, and its lower portion is a little below the point of the hook,
when, from the resistance which will now be met with, it is
satisfactorily ascertained, that the tooth is firmly taken hold of,
the operator gives to the instrument a strong motion of rota-
tion and elevation, and extracts the tooth from within outward
by two prompt and consecutive steps, the first to raise it and
* With regard to this matter, M. Begin expresses himself as follows :
(Diclionem et mot cites, p. 209.) "Hooks terminated by a single point may
also be used, this point is placed upon the gum, at a level with the middle
part of the root. When the key is armed in this manner the hook incises
the tissue of the gum, and takes hold of the root, which it raises and re-
jnoves."
OR MECHANICAL DENTISTRY. 305
the second to turn it out of its socket. The tooth in being ex-
tracted, comes from its socket in a hne of from forty-five to fifty
degrees.
Some practitioners, fearing that the turning down of the tooth
so low as above recommended will be often accompanied by
fracture of the alveolus, and desiring to bring the action of the
key to bear as near a resemblance as possible to the movements
of the forceps, which facilitate the extraction of teeth, sug-
gests that the tooth to be extracted should not be thrown down
lower than an angle of fifty-five or sixty degrees, but that the
same thing should be done in an opposite direction, that is to
say, toward the inner side of the mouth, of course turning the
key so as to make the hook act from the external surface of
the tooth — in a word, to luxate it both directions. This idea is
certainly, very reasonable, and its application to practice, would
have great advantages if the time necessary to reverse the hook
would not be a period of almost insupportable suffering to the
patient, and if the difference in volume of the teeth or the ex-
ternal surface were not greater than it is within, thus rendering
it more difficult to turn the tooth toward the inside of the mouth.
As this last objection, however, is not of serious consequence,
all that is desirable is to effect some arrangement by which the
reverse movements can be made without displacing the hook ;
that is, by two simple movements of the wrist. If to this im-
provement could be joined that of applying directly the hook
and bolster to the same tooth, the greater part of the objections
to the key would be removed, it would no longer present any
disadvantages, except those which attach to all methods of ex-
traction at present known ; with this one superiority, however,
the immense increase of power.
Generally, the entire extraction of a tooth is effected by means
of the key alone ; sometimes however, and we recommend this
expedient as a palliative for the disadvantages with which we
have reproached this instrument, after having effected the luxa-
tion of the tooth the operator stops just at the moment when he
feels that the alveolus would be fractured, and the gum torti,
and finished the operation by the means of straight or curved
forceps to which he gives a rotary motion, slight enough to
39
306 OPERATIVE MEDICINE AND PROSTHESIS,
avoid the threatened danger which induces him to arrest the ac-
tion of tlie key.
Finally, we will say a few words for the benefit of those who,
in spite of what we have already said on the subject, desire to
make habitual use of this instrument ; we would advise them
to be careful to have the bolster sufficiently large and thick, to
form a solid and direct fulcrum, without being liable seriously
to wound the mucous membrane and the gum which it covers ;
to have the shaft so curved that it will be prevented from injur-
ing the other teeth ; to have this shaft quite long in order that
the eye may follow the operation, and, particularly in order to
augment its power, as we have demonstrated in our remarks
upon the general theory of levers.
It is, besides, important to know that if the hook is not firmly
fixed, or has been carlessly applied, or is displaced by a move-
ment of the patient, it may slip partly off the tooth to be extract-
ed and partly on the one adjoining and draw out both teeth
at once. Finally when it is ascertained that the tooth is out of
the socket, it should instantly be released from the instrument
by a reverse movement of the wrist ; this is important as it often
occurs that the patient, satisfied to be disembarrassed of the
tooth, may make a movement which is liable to tear the gum
seriously, if a portion happens to be attached to the tooth.
2. The clavier^ after the key of Garengeot, is an instrument
more used than any other for the extraction of teeth ; it is a
species of forceps the beaks of which are bent in the direction
of their articulation, so as to resemble the two mandibles of the
beak of a parroquet : that is, the superior, which is a continua-
tion of the female branch, longer than the other, is curved from
above downward, so as to form a half circle, and the inferior
from below upward so as to form a quarter circle. The superior
branch is about six or eight lines long, measured from the point
where it leaves the joint, to its extremity ; the inferior is about
a line or a line and a half shorter, the extremity of each is about
a line and a half in thickness. The entire length of the instru-
ment is, generally, about six inches ; they are sometimes, how-
ever, made of smaller size as those intended for the extraction
of the deciduous teeth.
OR MECHANICAL DENTISTRY.
307
This instrument is particularly used for the extraction of the
large and small molars of the lower jaw, as also those of the
right side in the upper. If well made, the points of their beak
will nearly close, in order that the smallest pieces can be taken
hold of and they should have a degree of concavity perfectly
proportioned to the convexity of the body of the tooth which
they are intended to extract ; the handles, should be slightly
roughened in the manner that most of these instruments are
made to prevent the hand from slipping; they should neither be
so short and thick as to prevent the operator from handling them
with ease. The handles are both curved and straight : the first
form is that which was first adopted, but some practitioners pre-
fer them straight for the teeth of the upper jaw; because the
fingers are better able to appreciate the degree in which they
have been brought down than if they presented a convex line
upon which the fingers are liable to slip — this form oifers, be-
sides, other advantages.
The davier, when it is used, is taken in the whole hand, with
the convexity of the longer portion of the beak looking upward,
the thumb is placed against the rivet which unites the two
branches, the second phalange of the fore finger upon the oppo-
site side, and the little finger placed between the handles to open
the instrument and direct it at will. Thus held, it is introduced
into the mouth, and the shorter branch of the beak is applied
to the external face of the neck of the tooth ; then holding the
instrument firmly, the wrist is so elevated as to bring the beak
of the longer curve as far down as possible on the internal face
of the neck of the tooth, pressing down the gum. When cer-
tain that the tooth is firmly grasped, it is pressed down, and
drawn from within outward by a moderate and progressive ef-
fort at the same time that it is elevated, and some movements
back and forth made.
The davier evidently acts as a lever of the first order ; the
fulcrum, upon which the tooth presses at the moment of ex-
traction, is the short branch of the instrument which is fixed
against the external face of the neck of the tooth ; it is placed
between the resistance, which is that part of the tooth upon
which the long branch of the beak acts, and the power, which
is the hand of the operator, at the other extremity of the lever.
308 OPEKATIVE MEDICINE ANH PROSTHESIS,
There is a great analogy between this instrument and the key
of Garengeot, if not in their confirmation at least in their mode
of action : the longer branch of the beak of the former corres-
ponds to the hook of the latter, the other branch almost straight,
corresponds to the bolster of the key, the two handles taken to-
gether correspond to the shaft upon which the handle of the key is
fixed. But there are these differences betAveen the two instru-
ments, which are in favor of the davier : 1st. The shorter
branch of the beak, which forms the fulcrum upon which turns
the tooth, does not rest upon the alveolus, nor the gum which
covers it, but upon the tooth itself; 2d. The power acts in a
straight line and not as with the key, obliquely, which prevents
the appreciation of its actio?i.
When an operator is accustomed to the use of the davier, he
may apply it very advantageously for the extraction of the small
and the two first great molars, but never, (as Fournier, in his
^^ Dictionaire des Sciences Medicales,* and Maury, in his trea-
tise,! have advised,) use it for the extraction of the incisors, and
canine teeth of which it will be too liable to break the outer plate
of the alveolus. We have never been able to explain, to our-
selves, why a practitioner so experienced as Laforgue, should
have expressed an opinion so erroneous as the following : "The
davier should be employed for the extraction of all the teeth of
which it can take hold, and which the commissure of the lips
does not prevent it from reaching ; it alone is preferable to all
others for these cases."| Finally, several precautions are neces-
sary to be observed in the use of the davier ; the teeth should
be firmly seized on the side opposite to which the tooth is ex-
tracted, so as to prevent the head of the patient from following
the hand of the operator ; the operator should be careful not to
press too hard upon the instrument, as there is danger of crush-
ing the teeth ; he should also be careful to extract the tooth
in a line with the curvature of the roots so that they may not
be broken.
3. Thepi7icers,or forceps, in consequence of its ancient usage in
•Article Davier; tome viii., p. 88.
■\Ouvrage, cite p. 276.
XSemeiologie buccak, ou Traite des Signes, etc., p. 86.
OR MECHANICAL DENTISTRY. 309
the mechanic arts, it is very probable, was the first instrument em-
ployed in the extraction of teeth. It is either straight or curved :
the straight forceps, which is commonly used at the present
time, is about seven or eight inches long ; its jaws slightly
rounded, not more than six or seven lines in thickness, are so
made that the points appear to touch when they are closed, the
interior faces are hollowed out longitudinally, so as to give lodg-
ment to the tooth to be extracted ; the form and size of these
forceps are excessively variable. The handles are either arched
or straight ; the latter kind particularly when they are roughened
and a little enlarged at their extremities, are infinitely less apt to
slip during the effort necessary in the performance of the opera-
tion for which they are used.
The straight forceps are used for the extraction of the inci-
sors, canine teeth, and small molars of the upper jaw, but
only for the incisors of the lower jaw. In operating with
the straight forceps, the lips are raised with the thumb and
finger of the left hand, directly if the tooth to be extract-
ed is on the right side, but more ordinarily, passing the arm
around the neck if it is on the left side. The tooth should be
seized high up on the neck, under the gum, which should be
pushed up out of the way of the instrument; it should then be
seized with sufficient firmness to prevent it from slipping, and
yet care must be observed to avoid crushing the tooth ; the
evulsion of the tooth should then be effected by loosening its
attachments by varied movements of suppuration and demi-rota-
tion, as directed by Laforgue, the operator exercising traction
toward himself with sufficient force but without violence. We
have said here that a movement of suppuration should be given
to the instruments in extracting the tooth, because the hand,
armed with the forceps, presented to the tooth, should be prona-
ted ; the contrary is the case with the davier when it is used for
the extraction of the superior incisors.
When the attentive examination of a tooth to be extracted
gives reason to believe that it is firmly implanted in the jaws and
is excavated by caries, it is not advisable to attempt too soon to
shake it with the forceps, because it would be liable to break
under the effort. After each attempt, shght at first, the instru-
ment should be pushed further and fiirther up on the root.
310 OPERATIVE MEDICINE AND PROSTHESIS,
The carved forceps differ from the straight forceps in being
curved, and from the davier in being curved in a direction con-
trary to their articulation ; the jaws which are both of the same
length and move simultaneously are like the straight forceps,
hollowed out more or less deeply, according to the size of the
tooth to be extracted. The curved forceps are infinitely less
powerful than the davier, which instrnment acts as much in pro-
ducing the circular motion of the key as in extracting the tooth;
they are mostly used for the purpose of removing teeth already
luxated or which have been loosened by accident, and also to
reach those teeth situated far back in the mouth, or teeth half
extracted which offer little resistance, or fragments of bone, the
remains of broken teeth or fractured alveoli. Reduced in their
proportions, these forceps answer most frequently for the extrac-
tion of the deciduous teeth ; they are made of various forms by
which they are perfectly adapted to this use.
There is still another kind of forceps, bent twice between the
joints and the extremity of the jaws. This is an useful im-
provement for the purpose of reaching far back into the mouth,
or to hold the commissure of the lips apart, as the jaws of the
instrument are placed in a plane anterior or posterior to the han-
dles.
4. The lever is the most simple of all the instruments used
for the extraction of the teeth ; it is as its name indicates, an
inflexible shaft, the purpose of which is to raise up the affected
tooth; it is half tempered, partly rounded, but a little flattened
and slightly curved at the extremity. It is used principally for
two purposes ; for extracting stumps of teeth, and for removing
the molar teeth by turning them out of their sockets, they are
applied for this purpose, particularly to the wisdom teeth, the roots
of which are sometimes united so as to form a kind of pivot, and
only partially developed. This instrument is about five inches
long; the handle is fixed parallel to the shaft.
When used for the purpose of extracting roots, this instru-
ment is forced down deeply, between the wall of the alveolus
and the root to be extracted ; then, with one of the flattened
surfaces, which terminate the extremity, the root is removed by
a motion of the wrist from pronation to suppuration. It does
OR MECHANICAL DENTISTRY. 311
not, therefore, act, as most authors have stated, as a lever of the
first order, but of the third. The resistance is the part of the
root upon which the point of the instrument rests, the fulcrum
is the extremity of the handle which is held in the palm of the
hand, and the power is applied at the part of the instrument
seized between the fingers and especially between the thumb
and fore finger. It is important to correct this error into which
most authors have fallen ; for if it be made to act as a lever of
the first order, it must necessarily make the internal wall of the
alveolus its fulcrum, which would make it liable to be broken
and it would make it necessary to turn the tooth or root toward
the inside of the mouth, which is impossible.
When the simple lever is used for the purpose of extracting
wisdom teeth, one of its extremities is placed between that and
the first molar, so as to make a fulcrum of the latter, and by a
movement almost horizontal, causing the tooth to describe a
circular motion backward, it is made to leave its socket. It is
rarely in such cases that the teeth are entirely removed by the
action of the lever; they should be extracted, if they remain
slightly attached, by means of the curved forceps. The langue
de carjpBy is infinitely preferable for the extraction of the wisdom
teeth.
5. The pied- de-biche (hind's foot) is an instrument possessing
advantages which have not been generally acknowledged by
some persons, indeed, it has been completely proscribed ;* it is
a slight modification of the simple lever which we have just
described ; like that instrument, it is a simple metallic shaft, fixed
in a handle parallel to its length, but it is curved about three or
four lines from its extremity, and bifurcated at the point ; from
the heel of the curve is fixed a species of projection which is
also bifurcated.
The pied-de-biche is used for the extraction of roots ; for this
purpose, the cutting part, or rather the extremity of the instru-
ment, is forced between the gum and the neck of the broken
tooth or root by pressing down the gum, the root is then raised
by pushing from without inward, placing the point of the instru-
*M. Malgaigne is of this number ; see his work already referred to, p. 109.
312 OPERATIVE MEDICINE AND PROSTHESIS,
ment between it and the alveolus, and making a fulcrum close
by, by means of the projection which we stated makes a part of
the shaft. It cannot be denied that this instrument acts as a
lever of the first order, as its fulcrum is upon the edge of the
alveolus when the circular motion is given to the instrument ;
the pressure which would otlierwise be made is moderated by
sustaining the instrument at this place, or, to speak in physical
language, by the attempt to transform it into a lever of the third
order, so that the power will no longer be in the palm of the
hand, but in the fingers, as we have shown, when treating of the
extraction of roots by means of the simple lever.
Before making use of this instrument, it is very important to
ascertain, as nearly as possible, the degree of force which it is
necessary to employ. For if this force is insufficient, the root
will not be removed, whilst if it is much greater them is actually
necessary, the alveolus is liable to be fractured, and the parts to
be lacerated more or less badly, for, notwithstanding the caution
which may be observed to protect the instrument, either with
the thumb or with several fingers of the opposite hand, the im-
pulse which it is necessary to give may easily cause it to slip.
Besides the simple pied-de-biche, we have sometimes success-
fully used an instrument which acts precisely in the same man-
ner, but which has over this one, the slight advantage of taking
hold of the tooth at the same moment that it is raised out of the
socket. This instrument is like that which we have just been
describing, a curved lever, but composed of two parts precisely
alike and attached to each other, but being separable so as to
receive a portion of the neck of the tooth, and capable of being
then closed by means of a slide fixed on the shaft which is
formed by their union. This instrument presents, at one view,
the appearance of the letter T, of which the vertical shaft is sol-
idly fixed in a handle, and the horizontal is curved a little in a
direction opposite to its two extremities.
6. The langue-de-carpe, (carp's tongue,) is also a curved lever,
but its terminated point has the form of a bayonet. The part
which near the point, escapes from the shaft is flat, triangular
and a little pointed; some authors, therefore, and among others
Laforgue, call it a pyramidal lever, it is also called the lever of
Lecluse, or the trivelin.
OR MECHANICAL DENTISTRY. 313
This instrument, the advantages of which seem little known
to modern practitioners generally, is used principally for the ex-
traction of the third molars of either the upper or lower jaw, when
the adjoining teeth are close to them or separated but a little dis-
tance. The langue-de-carpe (carp's tongue) is ?^ perfect instru-
ment for the extraction either of the wisdom teeth, by being placed
between it and the second large molars, and also for this latter
by placing it between it and the first, and so on to the first small
molar, when the second is lost, because the canine teeth support-
ed by the incisors are sufficiently firm to answer the purpose
perfectly. Beyond this, however, it is unadvisable to go, as the
incisors are not sufficiently strong to bear the force necessary to
remove the canine teeth. The projection made by the triangu-
lar portion also enables the operator to search deeply for the
roots of the molar teeth, and the firm fulcrum presented to the
fingers by the curve which unites this part to the shaft, gives
great force to the power, at the same time that the fingers pre-
vent injuries of the mouth if the instrument should, unexpect-
edly, slip. The langue-de-carpe differs from the simple lever
and pied-de-biche, (hind's foot,) in having its handle fixed gen-
erally transversely to the shaft, like the key of Garengeot ; we
generally say for sometimes we have seen the handle fixed
horizontally like that of the key, but we have been unable to see
any advantages result from this arrangement.
The flatness of the extremity of the triangular part of this in-
strument makes its introduction between the teeth quite easy.
The operator should attempt to press the instrument so far in
between the teeth that the thick part may act, as there is then
less danger of loosening the sound tooth which acts as a fulcrum ;
but this is an accident which will never befal a practitioner ex-
perienced in the use of this instrument, for he will always be
careful to support the sound tooth with his thumb or fore fin-
ger, so that he may readily ascertain during the operation, if it
is giving way under the force applied ; when this does occur, he
immediately desists in the use of this instrument and substitutes
another for it. If it is desirable to extract a wisdom tooth, and
the second molar next to it is deprived of its support by the loss
of the first molar, this can be remedied by pressing firmly in the
40
314 OPERATIVE MEDICINE AND PROSTHESIS,
space a piece of ivory covered with linen ; in this manner any
danger of loosening the isolated tooth may be avoided.
We will take occasion to remark, here, that the fulcrum made
of the adjoining tooth by the instrument of which we have been
speaking, is not so liable to effect its removal as at first sight
might be believed ; for in the movements given to the instru-
ment, for the purpose of extracting the affected tooth, acting upon
it from the root toward the crown, necessarily acts upon the
adjoining tooth from the crown toward the root, which will of
course be more liable to press it down into the socket than to
force it out.
7. The lever a crochet et a plague^ (the lever with hook and
plate.) Besides the three species of lever which we have des-
cribed, there is an instrument which is used for the extraction
of certain roots and also some of the teeth; this is called by the
name which heads this paragraph. It is a steel shaft fixed in
an oval shaped handle, and terminated at the other extremity, by
a hook which bears a great analogy to that of the key. This
shaft,grooved longitudinally, is received into the groove of a plate
articulated with it and covered with a piece of cork or skin •,
this plate is about four inches square, and is pierced with a hole
which receives a screw fixing it upon the groove in the shaft.
In using this instrument the extremity of the hook is intro-
duced, as deeply as possible, below the level of the inner side
of the root to be extracted, and a fulcrum is made of an adjacent
tooth, or upon a small piece of wood applied upon it. A semi-
circular motion is then given to the instrument from behind for-
ward, or from before backward to remove the tooth which is
grasped. This species of lever as will be at once seen, holds a
place between the pelican and the key, but it is less certain than
either of these instruments, because the fulcrum is not so firmly
fixed. The modification of Maury, of making the hook mova-
ble, like the plate, is, in our eyes, far from being an improvement,
as it necessarily diminishes its solidity, we never make use
of it.
8. The pelican, as we have said, is generally thrown aside at
the present day ; but, as many practitioners still continue to use
it, we believe that we should say something of it, more, of
OR MECHANICAL DENTISTRY. 315
course, to show its disadvantages than to contribnte any thing
toward bringing it again into use.
This instrument, as it was used by the older dentists, as
Fauchard, for instance, and as it is still used in the north of
Europe, is composed of a handle, made formerly simply of wood,
but, at the present day, of ivory flattened upon both sides, ter-
minated by a rounded extremity, large and serrated, but general-
ly covered with skin or linen ; this serves as a fulcrum, whilst
the other end of an oval form, is received into the hand. In
the middle is screwed an elongated hook, the extremity of which
is curved like the beak of the bird whose name the instrument
bears; this hook falls in front of the fulcrum formed by the ex-
tremity of the handle which we have just described. The peli-
can is always provided with hooks of various lengths, so that
they may fall so far before the fulcrum as to be proportioned to
the thickness of the tooth to be extracted ; the free extremity of
the hooks, like those used for the key, is small and furnished
with too small sharp projections with a depression between them,
so as to prevent them from slipping.
The pelican, which has been substituted for the one we have
just described, differs in two respects ; first the fulcrum is a plate
of metal slightly concave, oval, about an inch long and an inch
wide, covered with skin and articulated with the handle by
means of a screw ; by this arrangement and the addition of a
screw for the purpose, the necessity of changing the hook is en-
tirely obviated, as this part of the instrument may be advanced
and brought back at pleasure. The credit of this improvement
is due, for the most part, to an English dentist named Bucking
and to Dubois Foucou.
In using the pelican, the hook is applied, like that of the key,
to the inner side of the neck of the tooth to be extracted ; the
extremity of the handle, which serves as the fulcrum, is applied
about eight or ten lines in front of the hook, upon the teeth
only, if the old pelican is used, but upon the teeth and gums if
the improved instrument is employed ; then, by a movement
which carries the instrument toward the median line, and by
which the hook is drawn outward, the tooth is turned out upon
the external side of the socket. If the extraction is not complete,
it is finished with the forceps.
316 OPRRATIVR MRDICINR AND PROSTHESIS,
From this description the truth of the assertion which we have
"^ade, that the peUcan has all the inconveniences, without any
of the advantages, of the key, becomes apparent. It acts, indeed,
Hke the key in turning the tooth out of the socket, and is, there-
fore, hable to produce all the injury which can result from this
movement ; but not having its fulcrum upon the tooth to be ex-
tracted, as is the case with the key, it sometimes causes the
loosening, and so often the loss of those upon which it rests,
that there is not a practitioner, familiar with its use, who has
not to regret some serious accident which has happened under
his hands, of which we might cite many instances. M. Begin
had also observed this result, for, after describing the instrument
Avith such minuteness as would authorise its use, he declares,
nevertheless, that nothing is more easy than the luxation of sev-
eral teeth when it is used.*
9. Finally, the disadvantages of the pelican in exercising a
repulsive lateral force upon the teeth adjoining the one to be ex-
tracted, and of the key by causing the tooth, in being extracted,
to describe a circular motion, struck us, so forcibly, in the out-
set of our practice, that about forty years ago, we constructed an
instrument which is free from either of these objections. This
instrument is so constructed that the extraction of the tooth is
effected in a straight line, and, at the same time that it is raised, it
exercises a vertical pressure upon the grinding surfaces of the two
adjacent teeth. It is, consequently, composed of three pieces ;
two are articulated to the middle part, the superior of which is
terminated at one extremity by a hook, similar to that of the
pelican, and at the other by a handle similar to the forceps, and,
at the inferior portion of the second part, which corresponds to
the hook of the first, there are two small wings between which
this hook passes ; the third piece is another hook, which, in
seizing the tooth, performs the office of the shorter jaw of the
davier, approaching the superior hook in proportion as the han-
dles of the instrument are pressed together.
But as these wings, if they were permanently fixed so as to
act upon the adjacent teeth, would prevent that lateral motion
* Diclionnaire ef, mots cites, p. 211.
OR MECFIANICAL DENTISTRY. 317
which should precede extraction, in all cases, we have made them
movable, so that hidden as they are in the instrument, they can
be brought at will to bear upon those teeth which are destined
to furnish them with a fulcrum ; in such case, they exercise
what might be called counter-extension, as when it has per-
formed the primitive functions of a simple davier. Finally, as
the tooth to be extracted is often isolated, we have for such
cases, constructed, in addition to the wings between which the
jaws act, other wings, fixed laterally, which find a fulcrum
upon teeth situated more or less distantly from the one to be
extracted.
This instrument then, strictly speaking, is only a species of
davier, from which it differs but little in size ; it has, however,
this advantage over it, that after the tooth is once loosened it re-
moves it in a straight line, by a simple pressure of the hand ;
this pressure being limited by the approach of the two handles,
can never exceed the desired point, and there is no risk, as in
the case of the davier, of striking it against the teeth of the
opposite jaw, if the tooth should give way suddenly.
Methods applicable to the Extraction of the Different Classes of
Teeth.
The nine instruments which we have just described, are
almost the only ones which are used by dentists at the present
day for the extraction of teeth ; and experience will demonstrate
to many, as it has done to us, that with a davier, a pair of for-
ceps, a curved lever, and, perhaps, our own instrument, which
combines the advantages of all these without their objections,
they may operate honorably in every case which presents itself.
If we now apply the precepts, omitted in the course of this
description, and indicate, in the order of the teeth, the instru-
ments and the method of proceeding, for the extraction of each
class, we will arrive at the following general rules:
1. Incisor and Canine Teeth. — The forceps should, generally,
be used for the extraction of the incisor and canine teeth of both
jaws ; but, for this purpose, neither the key, the davier, nor any
instrument acting upon a similar principle — that is, causing a
318 OPERATIVE MEDICINE AND PROSTHESIS,
circular motion — should be used, because the roots of these
teeth are long, and their alveoli thin, and as large breaches may
be caused by any accident occurring here, renders the patient
very much dissatisfied, every precaution should be taken to
avoid them.
In extracting the incisor or canine teeth of the upper jaw,
the operator should generally stand in front and on the right
side of the patient, so that he may incline the head in the posi-
tion most favorable for the operation ; but frequently, also, for
the teeth on the left side, the operator places himself behind the
patient, as we have said above. In extracting the teeth of the
lower jaw, it is always best to stand behind the patient ; in this
position all the anterior teeth, except the canine, are accessible
to the forceps. They should also be grasped as low as possible
under the gum, to prevent the instrument from slipping from
the slope of the posterior side of the neck of the tooth ; the in-
strument should also be pressed as strongly as possible without
breaking the tooth, and by movements of the wrist, made firmly
but without violence, the periosteum should be separated from
the walls of the alveolus. After the tooth is loosened in this
way, it is extracted almost perpendicularly. Sometimes the
tooth is not loosened in this way, until after many efforts have
been made ; for it has with truth been remarked by Fox, that
all the strength of a man might be used in a perpendicular direc-
tion, without extracting it; but after a tooth has been loosened
by an oblique movement to the right and left, it may be drawn
without difficulty. The teeth of children are always easy to
extract in this way, when it has not been thought possible or
convenient to take them out with the fingers,
2. Small Molars. — The teeth of this class are, generally, ex-
tracted with the forceps or davier, especially when they oflfer a
good hold for the instrument, and are not so much decayed as
to render them liable to break under the necessary pressure.
But each of these instruments has its special application : the
forceps are used exclusively for the teeth of the upper, and the
davier, is more applicable than any other instrument, for those of
the lower jaw. In using the davier the operator places himself
in front of the patient and a little to the left, if the tooth to be
OR MECHANICAL DEJSTISTRV. 3i9
extracted is on this side, and behind and a little to the right, if
the tooth is on the right side ; the manner of taking hold of the
tooth, and the movements given to the wrist, are precisely the
same in both cases. Practitioners who are well skilled with the
davier, may use it for the extraction of the small molars of the
upper jaw : the position of the operator will be the same as it is
for the lower teeth, in front and on the left, for those of the left
side, and behind and on the right for those of the right side ;
but, in either of these cases, the hand is held in the position of
suppuration, and the tooth is extracted jfVom within outward, and
from above downward. We often operate in this manner, but
for the right side only.
3. First large Molar. — The first two large molars are readily
extracted with the simple lever, or the langue-de-carpe, by plac-
ing these instruments deeply in the socket as directed when
describing them, and removing the tooth from below upward.
The operator should stand on the same side upon which he ope-
rates and not, as advised by Gariot, on the opposite side, as he
would then be obliged to introduce his instrument between the
teeth, from the inner side, which would be very inconvenient,
and would render the inner sides of the cheeks liable to be
wounded. But for the extraction of the first molar, which is so
near the front of the mouth as to be quite accessible, the davier
may be used, in most cases, in the same way that it is employed
for the extraction of the small molars. Those who are not ac-
customed to the use of the forceps, may, perhaps, resort to the key ;
in using it they should place themselves in front, and on the
same side from which the tooth is to be extracted, applying the
bolster on the external side of the tooth, and turning it from
within, outward ; and this for several reasons, because their
roots, incline a little in this direction, because the internal sur-
face, being straighter, furnishes a firmer hold for the hook, and,
being thicker toward the outer surface, if they were turned vio-
lently inward they would push apart the adjacent teeth.
The roots of the first molars, as we have seen, in studying
them anatomically, present very considerable variations. Some-
times these roots diverge to such a degree at their extremities
that it is physically impossible for them to be brought through
320 OPERATIVE MEDICINE AND PROSTHESIS,
the opening of the alveoh, so that, in their extraction it is
ahnost impossible to avoid either breaking the roots or fracturing
the socket ; sometimes one of the roots is very long and curved,
either backward or toward the side, penetrating deeply into the
jaw ; again they are so twisted that they grasp a portion of the
maxillary bone which inevitably comes away with them. All
these circumstances and many others, form obstacles which it is
difficult to surmount; unfortunately it is impossible to find any
indication, in the crowns of the teeth, of the multiplicity of their
roots, their irregular form or their divergence or convergence.
4. Wisdom Teeth.— The extraction of the wisdom teeth is,
perhaps, surrounded by more difficulties than that of any others,
not because they are more firmly implanted in the jaws, as we
know that their roots are often so united as to form but a single
one ;* but, first, because being situated further back in the mouth,
they are not so accessible to our instruments, because they are,
generally, not so well developed as the rest, and then there are
besides, inconveniences of position peculiar to each one. Those
in the superior jaw terminating the range of teeth are unsup-
ported posteriorly, and their crowns are so rounded that the va-
rious hooks, when applied to them, slip off easily ; those of the
inferior jaw are placed precisely at the place where the body of
this bone commences rising at the external side to form thecoro-
noid process, which, sometimes, at the time it is cut is almost as
high as the tooth.
The difficulty attendant upon the extraction of these teeth is
very often augmented, from the fact that persons affected by the
violent symptoms which so often accompany their eruption,
often deceive themselves with regard to the true cause of the
pain they suffer, and defer, sometimes, having recourse to
us until the accidental complications have rendered the ob-
stacles still more difficult to vanquish. The following case ta-
* Laforgue, is in error, to contend as he has done in the last work by him, to
which we have referred, p. 101, that this disposition of the roots of the wis-
dom teeth is met with but in a very small number of subjects. All anato-
mists truly assert that it is very common. The extraction of these teelh is
difficult enough at least, and it is quite unnecessary to add imaginary diffi-
culties.
OR MECHANICAL DENTISTRY. 321
ken, without selection, from a great number of others which we
have collected, in relation to the subject, leaves no doubt about
this matter.*
In 1822, our friend Dr. Olmade, was attacked with odontalgia,
with which he was tortured for three months ; the violence of
the symptoms was such that his mouth was closed, spasmodi-
cally, and he was compelled to subsist entirely upon liquid ali-
ment. One of us having had occasion to see him, at the time
his sufferings commenced, observed that one of the wisdom teeth
of the lower jaw was on the point of coming through; he attrib-
uted the disorder to this cause alone and advised the patient to
have it extracted. Dr. Olmade, deferred submitting to this op-
eration; but his gumssoon became inflamed, an abscess formed
which caused a fistulous opening through the cheek under
the whiskers. At the same time a portion of the maxillary bone
become necrosed and some fragments escaped with the pus.
At this time, becoming convinced that he could obtain no relief
from medicine, he determined to follow our advice ; but the oper-
ation could no longer be performed but with great difficulty. We
succeeded, however, by means of two triangular blocks of wood,
in opening the mouth gradually, to about a half inch , when we in-
troduced the forceps which we described in another place by
means of which we increased the opening and kept the jaws
stationary, at that point. Now introducing the finger in the
mouth, we discovered that the wisdom tooth was not completely
out; but the opening of the mouth was not sufficient to enable
us to proceed to its extraction, and we, therefore, found it neces-
sary, first, to remove the second large molar, the crown of which
was almost entirely destroyed. The roots of this tooth were
anchylosed to the alveolar walls in their whole extent, although
they were very short. It was to this anatomical arrangement to
which was to be attributed all the sufferings of the patient. The
wisdom tooth, in fact, not having room enough between the
angle of the jaw and the second large molar and not being ena-
bled to displace the latter, it had taken an almost horizontal di-
*This case is extracted from those which one of us has published in his
" These Jnaugurale sur les Dents de Sagcsse."
41
322 OPERATIVE MEDICINE AND PROSTHESIS,
rection from behind forward, so that the posterior face of the
crown presented upward. A short time after we effected its ex-
traction, the abscess and fistula closed, but the cure was not com-
pleted till after the lapse of two months.
This case, together with those which we have extracted from
the clinical lectures of M. Velpeau, one of which we have pre-
sented, and the other will be given in the following section,
will enable the student to form a just estimate of the difficulties
which the wisdom teeth encounter in their eruption, of the
gravity of the operation under some circumstances, of their ex-
traction, and the care necessary to be observed in the perform-
ance of this operation.
Extraction of Roots.
All the difficulties encountered in the extraction of teeth, and
that they are but too numerous we have just shown, will be met
with, also, in the extraction of roots of teeth, only that they will
there be found still more serious. The blind attachment of
the greater proportion of dentists to the key of Garengeot, is such
that they do not fear to apply this instrument as frequently for
the extraction of roots as for the teeth themselves. It will be
clear, however, to those who give themselves the trouble to reflect
a little, as we have demonstrated in speaking of the key itself,
that the hook, acting only in proportion as it bears upon the
body to be extracted, would be useless as applied to a body which
makes very little and often no projection, unless it could be
made to penetrate the cavity in which the body is concealed,
which is difficult to do with this instrument ; or which one can
only reach by piercing the alveolus, which is very inconve-
nient.
The absence of a projecting point is not the only cause which
renders the extraction of roots difficult. This difficulty often
arises from their being softened about the neck. This softening
sometimes extends so far as to affect them in half or two-thirds
of their length •, that which is sound is situated deeply in the
alveolus, or is intimately fixed by means of the alveolar perios-
teum \ or else, the caries having commenced in the dental cansfl,
OR MECHANICAL DENTISTRY. 323
has destroyed all the interior of the root, till it has left nothing
exteriorly but a very thin lamina of bone, altogether insufficient
to bear the pressure of the instruments necessary to their remo-
val. It is often the case, that the part of the root projecting
above the edge of the alveolus is covered with vegetations of the
mucous membrane of the gums, in consequence of the inflam-
mation which has followed the laceration of this membrane at
the time when the tooth was fractured. Finally, fistulous open-
ings are, generally, caused by the presence of roots, and these
necessarily complicate their extraction.
The detailed account which we have given of the mechanism
and mode of action of the different instruments used for the ex-
traction of the teeth, will indicate that the ones best adapted for
the removal of roots, are those which act on the principle of
the simple lever. The point of one of these instruments is
forced down between the circumference of the socket and the
root ; a slight effort of elevation from the side where there is the
least resistance, is often sufficient to remove it ; if it is very firm,
the same process is followed on both sides, and this generally
succeeds. But it often happens that the root, although loosen-
ed, still continues to hold so firmly as not to come entirely
away, either because the periosteum or the dental cord are
thickened and retain it, or because a vicious conformation pre-
vents it from following the line of the axis of the alveolus. If
the difficulty results from the first of these causes, the resistance
is overcome by thrusting the instrument deeply enough to act
upon the root as nearly as possible to its extremity, the operator
drawing it by a retractive force towards himself But if it
arises from the second cause, which, unfortunately, it is not easy
to foresee, this method of procedure is not sufficient to insure
success ; in such case, if the roots of a large molar are the sub-
jects of the operation, they should, if possible, be separated, and
drawn out one after another. This is done in the following
manner : the neck of the tooth is perforated with a drill, the
hole squared, and a strong cutting screw, with a firm handle,
introduced so as to break the roots apart. They are then ex-
tracted separately. Finally, if the means here pointed out should
not succeed, and it is important that the root should be extract-
324 OPERATIVE MEDICINE AND PROSTHESIS,
ed, the instrument should be pressed down between the root
and the external wall of the alveolus, which latter should be
broken away, and the roots extracted with curved forceps, more
or less sharp, according to the depth to which it should pene-
trate. This painful necessity exists particularly when the pre-
sence of the root we desire to extract is the evident cause of
some serious disorder, such as a fistula opening through the
cheek, a caries of the maxillary bone, etc. etc. This we have
experienced in many cases, of which the following is the most
remarkable :
The son of a rich merchant of Bordeaux, had been obliged,
in consequence of the intense pain he suffered, to resort to the
extraction of the first right lower molar tooth, which was deeply
excavated by decay. The dentist who was entrusted with the
operation, broke the tooth off close to the gum, and consequently
left all the root in the alveolus. Two years passed away, during
which the patient experienced no inconvenience from the root ;
but at this time, (he was then twenty-two years of age,) he felt
a constant sensation of tension, not only immediately about the
root, but in the adjacent parts, particularly towards the back part
of the mouth. It was not long before this feeling of tension
took the character of pain, and this pain in a very short time be-
came very troublesome. The dentist who had broken the tooth
was again consulted. Not doubting that the presence of the
root was the cause of the pain, he attempted its extraction, but
all his efforts were fruitless. He then advised the extraction of
the adjoining tooth, which, closing up the orifice of its alveolus,
prevented the extraction of the root. The father of the young
man, not believing that it was necessary to extract a sound
tooth, in order to effect the extraction of a root, and fearing for
this one the fate of the former, refused to allow the operation to
be performed, and advised his son to wait till their arrival at
Paris, to which city they were called by business, so that they
might consult in the case some of our celebrated surgeons.
On their arrival in Paris, they consulted Dupuytren. This
illustrious practitioner had scarcely examined the mouth or the
young man, when he perceived, from the deviation of the tooth
which covered the root, that the wisdom tooth, obstructed in its
OR MECHANICAL DENTISTRY. 325
eruption, had pushed all in front of it, and that, under its pres-
sure, the second large molar had been forced upon the root in
front of it, to such an extent that this latter had been buried in
the alveolar tissue, thus causing the incessant pain experienced
by the patient. He then advised that the displaced tooth should
be extracted, in accordance with the advice of the Bordeaux
dentist, and recommended the patient to M. Delabarre, Miel or
myself, to have the operation performed. The preference was
given to us. We immediately confirmed the diagnosis of the
celebrated professor of Hotel Dieu ; but we did not entirely
agree with him in the belief that the root could be removed
with ease, after the extraction of the tooth whose loss had been
determined upon. This tooth was first loosened with the langue-
de-carpe, and extracted with the davier; we then endeavored,
but vainly, with many species of lever, to extract the root. It
had been forced into the thickness of the alveolus. We were
then compelled to detach the gum as low down as possible, and
remove, with a small gouge, the external plate of the alveolus.
After the root was exposed in this way, its removal with the for-
ceps was easy. The operation was immediately followed by a
haemorrhage, which was arrested by a compress. Emollient
fomentations, assisted by repeated foot-baths, with mustard in
the water, and some derivative purgatives, arrested the conse-
quences of inflammation, and sufficed to bring about a cure as
complete as it was prompt.
When a number of adjoining roots are to be extracted, as it
is impossible to use the instruments for that purpose to so great
advantage as when they are next to sound teeth, it is well to
loosen them, by placing between them the langue-de-carpe,
to which is given a half rotatory motion. When roots are
so much hollowed out by caries as to transform them into
mere shells, as is sometimes the case with those of the canine
and incisor teeth, it would be presumptuous to hope to extract
them whole, and imprudent to promise the patient that you can
do so ; a very small lever should either be inserted between
them and the alveolus, or even into their interior, with which
they should be broken into fragments, which are easily removed
with a pair of common pliers. The roots of the wisdom teeth,
326 OPERATIVE MEDICINE AND PROSTHESIS,
especially, should be extracted with the langne-de-carpe, which,
by its curved form, can readily be made to penetrate more deeply
than any other instrument.
We will say, finally, that a dentist of long experience will
readily ascertain the amount of resistance which will be met
with in each case. Their presumed length, the thickness of
the alveolus, the condition verified by touching them, not only
of the corresponding tooth, but also of the roots, the swelling of
the maxillary bone, the age, the general constitution of the sub-
ject, are so many signs by which the difficulties likely to be
experienced in their extraction may be judged of. When it is
presumed that the resistance will be very great, the root, in most
cases, should first be loosened with the langue-de-carpe, and
when it is so moved that it offers a hold for the instru-
ment, curved forceps or the davier should be used. In a word,
the operator should be governed by the indications of good
sense, for no general rules can be made to apply to all cases.
We know but a single precept, which should be well understood,
and always present before the mind, that is, never to undertake
the extraction of a root with the pied-de-biche, without being
physically certain of success; for in case of failure, and repeated
attempts, with all the address possible, the loosening the other
teeth is unavoidable, and also the production of serious disor-
ders, and the rendering impatient and fearful those who with
the greatest readiness submit at first to the operation.
Extraction of Teeth situated out of the range of the Dental
Arches^ and of Concealed Teeth.
In all we have hitherto said of the extraction of teeth, we
have had in view cases only of common occurrence ; that is to
say, such cases only which related to teeth occupying their na-
tural positions along the dental arches ; but there are other cases
which require certain precautions, or rather, to which certain
particular rules are applicable. These are such, for instance,
where the teeth, situated out of the dental arches, are to be ex-
tracted ; and also those which may be concealed in the thickness
of the tissues, inaccessible to the sight, occasioning disorder
OR MECHANICAL DENTISTRY. 327
which can only be relieved by their extraction. We will ex-
amine the methods of procedure in both these cases.
1. Teeth situated out of the range of the Dental Arches. —
Whatever may be the situation of such teeth, their extraction
requires the greatest care, as we have heretofore had occasion
to say ; for, we repeat, if they are placed immediately be-
hind or in front of the other teeth, these latter may, in some
degree, be loosened by the effort of extraction ; and if they are
situated at a distance from the dental range, there is danger of
the instrument slipping, in consequence of the difficulty of
taking hold of them, or, in extracting them, to injure seriously
the surrounding parts, an example of which we have cited from
our own practice. For this reason, it is important that, in ex-
tracting such teeth as are situated near the alveolar border, they
should be removed with instruments acting in a straight line,
without causing a circular movement, which might have the
effect of compromising the firmness of those regularly situated
before or behind them. When they offer a sufficient hold, the
forceps are particularly adapted to their extraction ; the straight
forceps, when they are situated in front, and the curved when
they are situated behind the range of the other teeth, particu-
larly in the lower jaw. The precaution should always be ob-
served to sustain the adjacent teeth, by placing the fingers upon
their crowns, so as to become aware of their slightest movement.
But when these teeth are simple tubercles, as is generally the
case with supernumerary teeth, it will be difficult to take hold
of them with the forceps ; it will be necessary, then, to intro-
duce a lever between them and the regular teeth, when they are
near them, or into the socket, if they are too far from the regular
teeth to allow a fulcrum to be made of them. In such cases as
the last, it is often better, we repeat, to excise than to extract
them. Examples, however, will do more towards indicating the
proper course to be pursued under such circumstances, than
reasoning. We will report only the two following cases ; the
first of a canine tooth, situated entirely in front of the alveolar
border; and the second, of three supernumerary teeth, situated
within the dental range.
Case I. — Early in March, 1840, upon the recommendation of
328 OPERATIVE MEDICINE AND PROSTHESIS,
a young English lady, for whom we had brought into its proper
position an irregular lateral incisor, Mademoiselle M , aged
seventeen years, was brought to us by her mother, to know if
we could render the same service in the case of a superior canine
tooth, which, ever since its appearance, being more tardy
than usual, had occupied a place exactly in front of its regular
place. This tooth, directing itself more and more obliquely for-
ward, had caused an induration of the portion of the lip touched
by its point, and held it so much raised as to cause it to be dis-
figured. The slightest examination of the tooth convinced us
that all attempts to bring it into a regular position would be
vain. But as the mother seemed very strongly to entertain a
contrary hope, we begged to be [permitted to take a cast of the
teeth of the young lady, and it was very easy from the cast to
prove to her the complete impossibility of bringing the irregular
tooth into its proper place ; first, because the lateral incisor and
first molar, between which it would have to be brought, were
directly in contact ; secondly, because the portion of alveolus
situated in front of it was too thick to yield to any reasonable
amount of pressure which could be brought to bear upon it;
and, finally, because this pressure, even if it could be sufficient,
would only bring the point of the crown in the space toward
which it should be conducted, as it was implanted much above
the edge of the alveolus. This demonstration was too clear to
allow Madame M. for a moment longer to oppose herself to our
advice, and it was immediately decided upon to extract the
tooth. But in effecting this extraction, two things were to be
feared ; either that the forceps could not be made to pass so far
up on the neck of the tooth as to prevent them from slipping, or
that the action of the lever, which, in such case, would have to
be resorted to, would loosen the regular teeth so close behind it.
We therefore determined to extract it with the forceps, but not
to attempt to make an effort of traction, until we had displaced
it to such an extent as to allow us to push the jaws of the in-
strument far up on its neck. When it was once well seized, its
extraction was easy. But, fearing that the absence of the sup-
port to which the adjacent regular teeth had been accustomed,
would be prejudicial to their firmness, we fixed a metallic bar
OR MECHANICAL DENTISTRY. 329
in front of them, thus preventing their tendency to be thrown
forward. At the end of a month, the alveolus of the extracted
tooth had completely closed, we removed the fixture, and no
trace of the operation or the previous deformity remained.
Case 2. — Three months ago, a youth, fourteen years of age,
with three supernumerary teeth, on the inner side of the dental
arch, was brought to us. They were situated in such a manner
that the smallest one corresponded directly to the median line,
and the two others, each to the space which separates the mid-
dle from the lateral incisor, but a little farther toward the inner
side of the mouth than the former, with which they formed a
triangle. These teeth did not make their appearance till about
the eighth year. Their presence had caused an extraordinary
thickening of the anterior portion of the alveolar processes ; the
dilatation caused by this had separated the central incisors to
the distance of about four lines. Quite a remarkable feature in
the case is, that the supernumerary teeth seemed to have ac-
quired their size at the expense of the canine teeth, which were
so small as hardly to be apparent. We commenced by taking
a cast of this curious mouth ; a step which we would advise
every practitioner to take in extraordinary cases, as much for
the interestsof science, which always gains by their study, as to
render an account of the therapeutic indication which it pre-
sented. After this was done, we informed the parents of the
young man that the extraction of these teeth would not only
remove the sometimes painful obstruction caused by their pre-
sence, but that the space between the central incisors would
also close in proportion to the shrinking of the alveolar pro-
cesses, which their removal would bring about. We first ex-
tracted two, which were situated back of the other one, by
means of straight forceps, which we were very careful to push
as far up as possible, to prevent them from slipping. They
gave way with great difficulty, in consequence of a backward
curvature of their roots. We did not remove the third one till
a month after; but as it projected much less than the others,
we first loosened it by means of a lever, passed through the
space presented by the small size of the right canine tooth, and
finished its extraction with the forceps. Not more than two
42
330
OPERATIVE MEDICINE AND PROSTHESIS,
months have elapsed since these teeth were extracted, and the
space between the incisors is more than half closed ; and, as
the alveolar processes are not yet reduced to their ordinary
thickness, we are convinced that the lateral surfaces of these
teeth will finally touch.
As they have taken a slightly oblique direction forward it is
likely that we shall have to favor their retreat, by means of an
apparatus such as we have described in that jportion of our
work devoted to dental orthopedia. But we are inclined to
believe that nature will save us this trouble.
2. Concealed Teeth. — In the part which we have devoted to
anatomy and physiology, it has been shown that the teeth are
capable of being developed elsewhere than upon the alveolar
border, and of remaining for a long time buried in the parts ad-
jacent to the place which they should naturally occupy. These
teeth, however, almost always ultimately make their appearance;
but the difficulty with which their eruption is eifected is often
troublesome enough to constitute a state of disease, and their
presence is frequently the cause of phenomena the true charac-
ter of which may be completely misunderstood ; cases of this
kind have been related by Albinus,* Dessault,t Cavard,| Sa-
batier,§ and Laforgue. These cases are, without doubt, un-
known to the authors who have written the most recent elemen-
tary treatises, upon dental surgery, since they make no allusion
to them.
As the symptoms which indicate the presence of these teeth,
generally, take their character from the place occupied by them,
which is infinitely variable, and as the means adopted for their
extraction should be in accordance with this fact, we will con-
tent ourselves by citing four cases, which, from their great dis-
similarity, will give at once a general idea of the disorders
which these teeth may occasion, the proper diagnosis, and
the operations to which recourse should be had in order to give
relief. The first of these cases is taken from our own practice,
the second is from Laforgue, the third is extracted from Velpeau's
lectures, and the fourth from Fouchard. In this last case the
* Dt Sceleto Humano. { Traite d'^natomie.
Uournal de Chirurgic. §Medeciae Operatoire.
OR MECHANICAL DENTISTRY. 331
tooth had been buried in the tissues in consequence of the awk-
wardness of the operator.
Case I. In 1828,a lady about thirty or thirty-two years of age,
came to consult us about pain, sometimes very intense, which
she suffered in all the left side of the superior jaw, and which
had continued for six years, keeping her in a state of irritability
which the slightest emotion transformed into a nervous crisis.
Amongst the physicians who had visited her, some had pro-
nounced this pain the result of some rheumatic affection,
that sheet-anchor of many practitioners in doubtful cases ; others
explained the case by saying it was a lesion of the fifth pair of
nerves, against which no natural treatment could be success-
fully directed. What seemed to give some probability to this
last opinion was, the fact that when the greatest exacerbation of
the pain occurred, the hearing became obtuse and the face ani-
mated.
Tired out with the diversity of opinion, and especially with
the failure of the treatment advised, this lady had consulted
several dentists, who, at this period enjoyed the greatest reputa-
tion. None of them ventured to give an opinion as to the cause
of the pain, and all, after a careful examination, had the good
sense to refuse to remove one or any of the teeth which the pa-
tient begged, earnestly, to have extracted, but which nothing,
presented by their appearance, to the gentlemen, authorized
their removal. We were in all points of this last opinion, and
the patient left us, as little satisfied, of course, with us as with
the rest of those upon whom she had called.
We saw nothing of her for about two years ; but, in 1830, we
recognised her, in company with a young girl, ten or twelve
years of age who had been brought to obtain our opinion with
regard to her two superior central incisors which seemed about
to take a bad direction. We felt at liberty to make some inqui-
ries of her in relation to the results of the painful affection of the
face which had been the occasion of the honor of our first inter-
view with her. She replied that the pain she then suffered had
continued to increase, and that she had at last made up her mind
to resort to one of those dentists who do not reason, and who
complacently extract all teeth they are requested to extract.
332 OPERATIVE MEDICINE AND PROSTHESIS,
We begged her to permit us to make a second examination. In
examining the teeth on the left side of the superior jaw, we dis-
covered that one of the small molars was missing ; this fact had
escaped us the first time, and this proves that in making exami-
nations of this kind, too much care cannot be taken if it is de-
sired to avoid the commission of injurious mistakes.
Then, turning our attention, carefully, to the alveolar border,
we discovered that it was not only thicker than it is ordinarily,
but that there was a hard and circumscribed tumefaction, which
corresponded to a place between the remaining small molar and
the first of the three large molars. From this moment we had
no further doubt that this part of the alveolar border contained
the missing tooth, and when we expressed this opinion to the
patient, she desired that we should take steps without delay to
make certain of the presumed fact. A slight incision was made
with the bistoury upon the most projecting part of the tumor;
the kind of resistance to the instrument, which we experienced,
left no doubt, and authorised us to push our examination far-
ther, and we soon discovered a small molar lying transversely
with the crown forward. It was easily loosened with a curved
lever, introduced between it and the posterior face of the teeth
in front of it, and then extracted with a pair of curved forceps.
The wound suppurated for six or eight days, after which it
healed, and the pain disappeared permanently.
Case 2. In 1813, a man having a fibrous tumor situated in
the middle of the roof of the mouth, came to consult Laforgue.*
From time to time, a whitish odorless matter escaped from the
side of this tumor which was about the size of an ordinary
cherry-stone. A number of surgeons who had seen the case,
were of opinion that the roots of the incisor teeth (still in place)
either caused or sustained this affection. The crowns of these
teeth were gone, having been destroyed by softening and caries.
Laforgue removed three of these roots and left one, at the right
side, which was firm and not at all painful. None of the roots
presented evidence of being, either directly or indirectly, through
their surrounding alveolar tissue, connected with the affection
of the palate, which fact Laforgue communicated to the patient.
* Dernier outrage cite, page 76, et Suivanles.
OR MECHANICAL DENTISTRY. 333
Suppuration from the side of the tumor recommenced. This
tumor was cauterized with the actual cautery twice in the
space of ten days by Boyer. Pelletan was of opinion that it was
a case of caries of the jaw; Dubois, that the remaining root was
the cause of the continuance of the disease, and advised its ex-
traction. Dupuytren was also of the latter opinion. Before
leaving the patient, however, Dupuytren observed, that although
the whole alveolar border was free from any indications of dis-
ease, it was thicker than is commonly the case after the teeth
have been lost. He, accordingly, made an incision of the gum,
over the part which projected most ; this point corresponded
with the alveolus of the lateral incisor of the right side ; but
he found neither fluid nor anything to direct his attention to the
cause of the affection. The root was extracted by Laforgue,
who discovered, what it was impossible to distinguish previous-
ly to its extraction, as it was almost covered with the gum, that
it was the root of a small molar tooth. The condition of the
alveolar periosteum and of the root, satisfied him that it was not
the cause of the tumor of the palate. As he had previously ex-
tracted several roots, amongst which was not that of the canine
tooth, which gave no evidence of its existence, and as the pa-
tient asserted, positively, that he had had none of the roots ex-
tracted, except by him ; Laforgue was led to believe that the
canine tooth was situated along the alveolar border. He told
the patient, of his suspicions, and was begged by him to have a
consultation with Dupuytren, which was agreed to.
The grounds upon which Laforgue came to this conclusion
were, that, notwithstanding the loss of the incisor teeth and
root, the alveolar border had not diminished in size, but, on the
contrary, it was so much enlarged as to lead to the belief that
some body was contained within it. The patient possessed a
great deal of firmness, submitted himself into their hands and
allowed them to make the necessary examination. The result
was, that the canine tooth was found situated in the same place
from which the roots had been extracted, but a little posteriorly.
The crown was toward the left side, the point touched against
the alveolus of the canine tooth of this side; the root was turn-
ed toward the right side and behind the root of the small molar
334 OPERATIVE MEDICINE AND PROSTHESIS,
which had been extracted in the morning; the external face
was turned downward. The tooth was incrusted, about two-
thirds of its whole length, and adherent to the maxillary bone.
The extraction was affected with a pyramidal lever,* the point
being placed upon the posterior face of the tooth ; the triturating
surface of the left small molar, which was supported by Dupuy-
tren during the operation, was made the fulcrum. The opera-
tion was performed slowly and gently, without the production
of much pain. All the effects of which it was the cause rapidly
passed away, and the wounds healed without any other reme-
dies than an emollient gargle used the first two days, and after-
wards the vin mielle.
Case 3.f M. M , an old artillery officer, living in one of
the provinces since 1815, came to Paris for the purpose of
placing himself under treatment for a syphilitic affection, which
he had contracted during his campaigns, and of which he be-
lieved himself imperfectly cured. Several months before, an ul-
cer had formed near the base of the tongue, rendering very
painful every motion of this organ. Mastication, particularly,
was sometimes painful to such a degree that he was compelled
to rise from the table without being able to eat. The mercurial
treatment to which he was submitted by the most distinguished
practitioners of the capital, far from curing the disorder, had the
effect only of aggravating it ; and the tongue, after fifteen or
twenty days' treatment, was tumefied to such a degree as nearly
to fill the mouth. The gums were engorged with blood, the
breath fetid, and the teeth loose ; the administration of mercu-
ry was entirely suspended, and the mouth, after sometime, re-
assumed the condition in which it was when M. M left
his province.
At this time he called on M. Toirac, to get him to remove from
his teeth the tartar which had collected upon them in consider-
able quantity, he spoke of his disorder, and related to M. Toirac
what we have presented. This practitioner, after depressing the
tongue towards the leftside, by means of a spatula, perceived at
*The instrument, thus named by Laforgue, is the same as that general-
ly known, as the langue-de-carpe.
t Legons cliniques de M. Verpean; tome iii., p. 385.
OR MECHANICAL DENTISTKY. 335
its base, the ulcer, resembling quite nearly, such as are generally
attributed to syphilis ; the circumference was swollen, and of
a dirty gray color. The nausea which this caused the patient
compelled him frequently to suspend his operations and the ex-
amination was, for this reason, very imperfect; this was not ef-
fected, indeed, until after repeated attempts ; allowing M. M
to rest from time to time; at last after a long examination, he
succeeded in discovering upon the square portion of the lower
maxillary bone, about six lines from the posterior dental canal,
a hard body covered with a portion of the gum floating loosely
and preventing him from distinguishing it perfectly. When
this excrescence was removed, a piece of tartar was discovered,
and taken away with a curved scraper. Under this, was anoth-
er white body, which was found to be part of the crown of a
wisdom tooth, imperfectly formed. This tooth, situated irregu-
larly, came in contact with the base of the tongue and was the
sole cause of the disease in question. Contending against the
obstructions offered by the tongue, and the repeated nausea ex-
perienced by the patient, M. Toirac made many attempts to
effect the extraction of this tooth ; it broke, however, under the
forceps, the only instruments he believed admissable in the case,
but it broke, happily, in such a manner that the portion of root
which remained, did not come in contact with the tongue. The
patient was very promptly cured.
It is our opinion that, after the root was discovered, it would
have been more prudent to have first loosened it with the sim-
ple lever, or with the langue-de-carpe, with either of which in-
struments it could certainly have been reached, as they are much
smaller than the forceps, which were brought to bear upon it.
By this preliminary precaution, the extraction would, perhaps,
have been rendered more easy, and the necessity of leaving be-
hind a root which might become the cause of future trouble
would have been avoided.
Case 4.* — "In order to show the great importance of not
trusting to any but experienced persons in cases of consequence,
I will relate here, the circumstances of the unpleasant condition
* FoucHARD ; ouvrage cite, tome i. p. 391, et SuivatUes.
336 OPERATIVE MEDICINE AND PROSTHESIS,
in which M. Henri Anianton, (son of M. Amanion, Esq., seig-
neur de BeaurecoBil, parish of Nonette, etc.) found himself in
1720, by having placed himself in the hands of a charlatan.
This was done on account of a canine tooth which, in conse-
quence both of its size and situation, was a source of much in-
convenience to him : it was situated towards the internal face of
the first small right molar of the upper jaw, and inclined con-
siderably towards the palate. The inconvenience and pain
caused by this tooth determined the gentleman to have it ex-
tracted ; and having made this resolution, he put himself in the
hands of an operator, who, after placing him in what he thought
a suitable position, applied a pierced key upon the extremity of
the crown and then struck heavy blows with a stone upon the
key ; by this manoeuvre he forced the tooth almost through into
the maxillary sinus and buried it so deeply that it was no
longer visible. When the tooth had disappeared in this way, the
empiric assured the spectators that the patient had swallowed
it. This appeared plausible enough, as a search for the tooth
was made in vain. Some time after, the patient experienced at
this place, considerable pain, which induced him to consult his
physician who found upon the cheek, near the nose, a small
hard tumor, free from inflammation, and inside the mouth he dis-
covered three very small fistulous openings which gave passage
to a very fetid serous matter. Sometime after, two other fistu-
lous openings appeared upon the tumor. Many consultations of
the surgeons of Clermont, where the patient was conveyed, and
at Paris, by M. M. Arnault and Petit, were held upon the case.
These last named gentlemen examined the paper which con-
tained a detail of the case, and perceived that it was sufficiently
important to be treated with great care. They gave their opin-
ion, which was sent to Clermont, but the surgeons of this city
not having undertaken the case, either because it appeared too
difficult or because they did not inspire sufficient confidence,
and the patient came to Paris and placed himself under the
hands of M. M. Arnault and Petit. These two surgeons soon
relieved the patient of his troubles. After dressing the parts for
ten days, M. Petit extracted the tooth successfully, which ope-
ration he performed by making an incision into the tumor, sup-
OR MECHANICAL DENTISTRY. 337
posing it to be occasioned by the extremity of the root of the
tooth. Having discovered this root, he seized it with a pair of
straight forceps and drew out the whole tooth. Finally, after a
few days the patient was cured by ordinary remedies, without
having his face at all deformed, scarcely indeed would one have
supposed that an incision through the skin had been made.
Recapitulation of the Rules applicable to most cases of Extraction.
Whatever tooth or root is to be extracted, whatever ptace it
may occupy, or whatever instrument may be used for this pur-
pose, the certainty of the success of the operation is Justin pro-
portion to the precaution observed by the operator, first to take a
sure hold of the tooth, and then to obtain a firm fulcrum for his
instrument. It is particularly important to obtain a solid ful-
crum, when the lever is used, for otherwise, it may escape from
the part to which it is applied and wound the adjacent parts ;
the forefinger should be placed near the point of the instrument
in order as it were to watch over its movements.
We have said that the tooth should be seized as far upon the
root as possible, and the question now presents itself, whether
it is necessary first to lay bare this portion, that is, whether the
gum, which is adherent to the neck, should be separated from
it and pushed upward or downward, as the case may be, to give
place to the instrument. The older dentists never failed to take
this precaution, which they regarded as the first step in the ope-
ration.* For this purpose they used an instrument which was
called, and which is still named, dechaussoir ; this was a steel
shaft, solidly fixed in a handle, with a blade of some five or six
lines, curved in the form of a crescent, cutting on its concave
edge, and terminating in a point — in a word, the same instru-
ment now used for opening abscesses situated far back in the
rnouth, and to incise the gums when they present an obstacle
to the free eruption of the teeth.
This precaution is at present generally considered useless.
Fox is almost the only author who has recommended it, and
*Foyez Fadchabd ; ouvruge cite, 2d vol., p. 130.
43
338 OPERATIVE MEDICINE AND PROSTHESIS,
he advises the substitution of a common lancet for the dechaus-
soir, properly so called ; but we do not regard this as a happy
substitution, especially as Fox does not mean the blade of a
lancet fixed firmly in a straight handle. The reasons which
have been given for the abandonment of this practice are, that
if the tooth is only adherent by the gum, the slightest effort of
traction, or turning over, wisely calculated, is sufficient to break
up its adherence ; and if, on the contrary, the tooth is firmly
set in the alveolus, the separation of the gum from the neck will
not only do no good, but, in many cases, will disgust and alarm
the patient, who is naturally disposed to judge of the pain of the
operation by the preliminary. If the alveolus breaks, it is evi-
dent that the gum will quite as readily be lacerated, as if it had
not been separated from the neck of the tooth. The same is the
case with regard to the incision of the gums advised by some
writers, for the purpose of uncovering roots to be extracted ; the
practice is generally renounced, because it does very little
towards exposing them, and occasions a flow of blood, which
hides the parts upon which we wish to operate.
The lancing of the gum becomes, however, not only a useful
but necessary operation, if it so passes the neck of the tooth
that, in the perfect application of the beak or hook of the instru-
ment, the operator would be obliged to seize them also, as this
would cause pain, which would greatly aggravate that of ex-
traction itself.
When the tooth is properly seized, and a good fulcrum se-
cured, care should be observed in the manner of using the
instrument employed. The practice of extracting the tooth
rapidly, by a sudden and violent movement of the instrument,
cannot be too much deprecated. We have seen such sad results
follow this method of procedure, that we cannot express our
disapproval in terms too strong. We will here cite a case from
the last author to whom we have referred, as evidence of what
may be the results of such a practice.
"Six years ago, I was consulted by a lady, who was suffering
much pain from the results of the extraction of a tooth, which
was done in a very rough manner. This tooth, the second
inferior bicuspis, having been extracted with a violent effort of
OR MECHANICAL DENTISTRY, 339
the operator, two or three days after the cheek became much
swollen, and an abscess was formed, which discharged itself
through the alveolus of the extracted tooth. At this time we
were called in, the pus was being discharged in abundant quan-
tity, and the other bicuspis, which began to grow loose, soon
became pamful, and appeared to be a cause of irritation. I
thought proper to extract it, and some time after there was ex-
foliation of several pieces of the jaw. The pain she suffered,
however, did not diminish ; the first molar, affected by the ab-
scess, began also to grow tender. It was also extracted, and after
the operation I was enabled to remove a large portion of the
exfoliated bone. The discharge then ceased, and the affected
parts were soon perfectly healed. In this case we see that three
teeth were lost for one which was diseased, an exfoliation of the
jaw, and six months' excessive pain, caused entirely by the
imprudence of a surgeon, who had operated with a sudden and
violent effort.*
We therefore repeat, that a tooth cannot be satisfactorily ex-
tracted, if its adhesion to the jaw is not overcome by a force
which, increasing gradually, causes its attachments to yield
without damage to the adjacent parts. It results, in consequence
of a deviation from this principle, that accidents without num-
ber occur, that teeth are so frequently broken in their sockets,
and that sometimes considerable fractures of the jaws occur.
In operating, then, the degree of force used should be increased
till the tooth is loosened, and an effort made, by raising the
hand, to draw the tooth in a direction as nearly perpendicular
as possible; in a word, less force than address should be
used.
This is what is implied by Gariot,when he expresses himself
as follows : "In the extraction of teeth, there is a physical
principle which should not be lost sight of, that every time a
body is distended more quickly than it yields, it will break.
For this reason, the effort to effect the extraction of a tooth
should be gentle, moderate, continuous and without the least
sudden impulse. If this important observation is not lost sight
* Ouvrage cite, page 257, et suivmtes.
340 OPKRATIVE MEDICINE AND PROSTHESIS,
of, teeth will rarely be broken, an accident which is of trifling
character, but one which is sufficient to ruin the reputation of a
dentist who may have much merit.* The ancients were so
well aware of the wise moderation and address necessary to
effect the extraction of the teeth, that they admitted and set
down as a principle, that forceps of lead were sufficient for the
purpose. This is attested by the instrument placed in the tem-
ple of Apollo, at Delphos, the knowledge of which, according to
M. Duval, is due to Erasistratus, who lived about two centuries
after Hippocrates.
If it is always important to refrain from rough and sudden
violent efforts in the extraction of teeth, this necessity is par-
ticularly indispensable in those cases, which are quite common,
where it is necessary to operate on the teeth situated in dis-
eased tissues, or required to be extracted in consequence of
some grave alteration, as in case of fracture of the jaw or resec-
tion of the bone. This is one of those exceptional cases, hap-
pily rare enough, in which any infraction of this rule would
have very unfavorable consequences, and in which an inexpe-
rienced dentist would need great coolness to avoid the betrayal
of his want of practice.
In the course of the year 1839, a woman of forty or forty-five
years of age, stooped down to feed a hog, and speak to it. The
animal rushed suddenly upon her, bringing its upper jaw in her
mouth, and knocking inward twelve of the lower anterior teeth.
This was impossible to be effected, but by a kind of separation
of the alveolar border of the maxillary bone itself. A surgeon
was called in, replaced the parts as well as he was able, without,
however, fixing the teeth properly, and secured the whole with a
bandage. The union of the alveolar processes was being effected
in the position in which the parts had been placed, but the teeth,
particularly the incisors, canine teeth and small molars, occu-
pied such an oblique position, that they pushed out the lips, ex-
coriating them, and giving to the physiognomy a hideous as-
pect. In this condition, the woman presented herself at the
Hospital de la Pitie, in order to have this deformity corrected.
* Traite des Maladies de la Bouche, in 8vo, avec fig., 1805.
OR MECHANICAL DENTISTRY. 341
Professor Lisfranc, with whose particular friendship we are
honored, desired that we should be called in. We went, and
in the presence of the pupils and teachers, showed that it was
proper that the teeth should be extracted, but by an effort of
traction, in the direction of the line which they described, and
not by any circular movement, which might have the effect of
weakening, if not rupturing entirely, the cicatrization of the
osseous parts, which had taken place underneath them. These
teeth were, consequently, seized with the forceps, slightly
loosened by lateral movements, a sort of counter- traction made
upon those which were adjacent, as they came away singly ;
all were finally extracted with the greatest success, and much
to the satisfaction of the professor, who took great pains to give
evidence of that fact.
M. Lisfranc, also, sent us one of the inmates of the hospital
over which he had control, for whom he had performed the
operation of resection of the inferior maxillary bone, upon the
stump of which a large molar tooth was still remaining ; the ex-
traction of this tooth, which had become necessary, required so
much the more prudence as it was precisely at the alveolus of
the corresponding tooth of the same jaw that the disease, for
which the operation which was performed, had had its origin.
As to such teeth as, from their union with the jaw, or the
conformation of their roots, can scarcely be extracted without
being accompanied by some alveolar fragments, as it is exces-
sively difficult, if not impossible, to ascertain their unfavorable
form, and as the prognosis besides, would only intimidate the
patient, it is impossible for the dentist to exculpate himself from
the accusation of having, from want of skill, caused the pain
which has been occasioned, by demonstrating that it was im-
possible to avoid the accident. Necessity and practice will, be-
sides, point out certain expedients, belonging rather to the
trade than the science, which will enable the operator to efface
all evidences of the accident or to conceal it from the eyes of the
patient who has been the subject of it.
Nothing now remains but to point out the steps which should
follow the operation, always after the dentist is well assured,
both by a careful examination of the mouth, and the root of the
342 OPERATIVE MEDICINE AND PROSTHESIS,
extracted tooth, that nothing, whicli can cause future trouble,
is left in the alveolus.
The first thing to be done is to allow the blood to flow for
sometime before causing the patient to rinse his mouth. It
is sometimes well to favor this flow of blood by lotions of warm
water, particularly with persons affected with inflammations of
the gums ; in such cases the use of tonic, aromatic or acidulated
gargles, should not be advised except in cases where the wound
bleeds several hours after the operation.
Pressing the gums together with the fingers is a common
precaution, directed rather by a desire to reassure the patient
than by a positive indication, at least when they have not been
greatly separated in the operation, or when a portion of the alveo-
lus has not been broken. In the latter case the fragments should
be removed ; for this purpose the fingers ordinarily suffice, but it
is sometimes necessary to use forceps with small beaks, such
as we recommended for the extraction of roots. Finally, it will
will be prudent to direct the patient to guard his mouth for some-
time against the impressions of the cold air, to avoid exercising
suction of the gums, which might occasion excessive haamorr-
hage, and for two or three days, from time to time, to wash his
mouth with aromatic and spirituous lotions.
Of the Accidents ivkich may Result from the Extraction of the
Teeth.
Notwithstanding the assertions of some modern authors con-
fiding, too implicitly, in the resources of the art, or, perhaps, too
well satisfied of their own skill, the extraction of the teeth is
sometimes followed by accidents which the most prudent and
adroit dentists cannot possibly avoid, because they are depend-
ant upon certain anatomical irregularities of which there is no
external indication, or upon some casual circumstances against
which the wisest foresight will find itself entirely at fault.
These accidents are of three kinds : they either result from a
general derangement of the economy caused by the operation
itself or the preparations for it; or it consists in the fracture of the
tooth to be extracted ; or, finally, it depends upon some lesion^of
the adjacent parts, as the bruising or lacerating of the gum
OK MECHANICAL DENTISTRY. 343
excessive haemorrhage — denudation or fracture of the alveoh —
the loosening, luxation, fracture or complete extraction of the
adjacent teeth — the fraction of either jaw, or the luxation of the
inferior jaw.
General or Nervous Accidents. The teeth are, constantly,
exposed to diseases from so many causes that few persons have
the privilege of escaping the operation of their extraction ; and
amongst the numerous class which has been forced to submit
to it, there are none who have not been forced to conclude that
no skill of the operator or perfection of instruments can guaran-
tee it from being painful. But, on the other hand, the pain
produced, (sometimes very acute, and bearing a peculiar charac-
ter,) is almost always of but instantaneous duration ; so quickly
over, in general, that it is often a source of regret to the patient,
that he has hesitated between dread of the operation and the
desire to be rid of the diseased tooth.
There are cases, however, in which this pain is of longer du-
ration and becomes the cause of nervous accidents, well calcu-
lated to alarm the inexperienced practitioner. These we have
known often to occur with very nervous persons, particularly fe-
males and children. Sometimes a long fainting fit is produced,
sometimes a general tremor, a general attack of the nerves, and
indeed, epileptic contractions or true tetanus ; these effects may,
in some cases, cause in females a suppression of the menses and
even produce abortion. This latter eflect is, however, of such
rare occurrence that pregnancy does not contra-indicate the opera-
tion, as we have already said in opposition to the opinion of M.
Oudet, particularly when this operation seems to be the only
means of relieving intense and obstinate pain. We are surprised
to perceive practitioners partaking of this prejudice, which was
formerly opposed by Fauchard and Bunon. Fauchard says
with regard to this matter:* "We often see women and nurses,
tortured with very acute pain, in consequence of carious teeth,
and we do not hesitate to extract them, notwithstanding their
pregnancy and the vulgar opinion, that injury may result from it;''
and Bunon :f "This letter encourages me to give a disserta-
* Ouvrage cite, tome, 1, p. 202.
t Exper. et Demonst. Faitcs, etc., Pour Fairc Suite a VEssai sur les Mala-
dies des Dents, 1 vol. l2mo, 1746, page 62.
344 OPERATIVE MEDICINE AND PROSTHESIS,
tation upon the teeth of pregnant women, in which I will show
the infinite injury which results both to them and their offspring
from the dangerous prejudice against touching the teeth of wo-
men who are enciente.*
If the operator is unable to avoid the production of pain, he
can, at least, render the necessary preparations less frightful, by
assuming a gentle and encouraging deportment; for, in good
physiology, it will be easy to prove, that without dread of the
operation, which has an unfavorable influence upon the brain,
the nervous accidents attendant upon the operation will not oc-
cur, or if they do, will be so mitigated as to be of trifling conse-
quence. But it is particularly the case when the operator fails
to accomplish his purpose at the first attempt that all subse-
quent efforts produce alarm; it is, therefore, important not to
disdain any precaution which will insure the success of the first
trial, and it should never be forgotten that of these two precepts
of operative medicine : cito ct tutb, (promptly and surely,) the
first is always to be sacrificed to the second.
There are besides certain moral characteristics which should
make it a duty with the dentist to refrain from operating ; these
he should early accustom himself to discover, to avoid the em-
barrassment which would result from an imperfect or very pain-
ful operation. Having stated that fainting and syncope is some-
times a result of the extraction of teeth, it follows that the office
of a dentist should be supplied with bottles of volatile salts,
which are used generally under such circumstances.
Fracture of the Teeth. — As we have already stated, a tooth, in
the course of the operation of extraction, may, from a variety of
causes be fractured : this may occur because the whole of the
interior crown of the tooth is so much destroyed by caries that
it cannot bear the pressure of the instrument ; or because the
roots are longer than was suspected by the operator, not so strong
as the alveoli, and convergent, embracing a considerable portion
of bone, or bent inward in the form of a hook, or finally efiect-
ed with exostosis, a case of which, we will presently relate ; or
* These two quotations prove that M. Begin (Dictionn. ct Mot cites) is
mistaken in stating, that these two authors greatly dread the extraction of the
teeth of pregnant women.
OR MECHANICAL DENTISTRY. 345
because the operator has either made use of an improper instru-
ment or has fixed the faicrum too directly in face of the power,
which then, rather crushes, than raises it; often too, in conse-
quence of the patient having pushed away or grasped the instru-
ment or the hand of the operator just when he was about to use it.
Gariot regarded the fracture of a tooth as a trifling accident;
we do not agree with him, not so much because it may have the
effect of injuring the patient, as because serious consequences
may result from it. The presence of the root of a tooth, after
its rupture, may cause insupportable suffering, and it is not al-
ways possible as Fournier,* has, with reason, remarked, to find
a dentist sufiicienly practised to extract this root when it offers
no hold for his instrument, is irregularly implanted in the socket
or malformed. This physician had some sad experience of this
fact, for he declares that for three years, he carried the root of a
tooth which caused him indescribable suffering. He thus re-
counts the event which placed him in this uncomfortable con-
dition.
"A dentist who desired to give me a proof of his dexterity
and the rapidity with which he extracted teeth, broke off one of
mine; it was the dens sapientiae of the lower jaw : the wretch-
ed fellow attempted, but vainly, to extract the root, and men,
justly celebrated for skill in their profession, also attempted it un-
successfully."
M. Catalau, finally relieved him of it. But it must be said,
in justification of the dentist, to whom Fournier had recourse,
that the tooth was rendered more difficult of extraction because
it was implanted obliquely in the jaw, and one of the roots was
affected with an enormous exostosis, and was curved backward
towards the coronoid process.
When the fracture takes place above the edge of the alveolus,
so that it can be seized by an instrument, the attempt to remove
it should be the same as if it were a sound tooth, upon which
no attempt at extraction had been made. In the contrary case,
when the fracture is below the edge of the socket the dentist
should proceed just as he would have done if he had been orig-
* Voyez le Mot Dent, deja cite, du Diclionnaire des Sciences Medicates.
44
346 OPERATIVE MEDICINE AND PROSTHESIS,
inally called upon to extract a root of the same character, at least
if the portion remaining is not too small or too deeply buried in
the socket. If it is a root which has been a long time deprived
of its crown, that is the subject of the fracture, and it is soft and
friable as is often the case with the anterior teeth of the lower
jaw, it should be removed by the lever, piece by piece, if it
should break.
It often happens, as we have already stated, that every portion
of the root of a fractured tooth cannot be extracted; in such
case we would advise the use of emollient and anodyne fomen-
tations, relaxing drinks, foot-baths, and wait till the time when
nature will have effected the destruction of a part of tfie alveo-
lus, detached the gum and exposed the root, when its extraction
will be quite easy ; it is not rare either that two or three days
after the accident the remaining portions remain loose in the
alveolus and are more easily extracted than they would have
been on the day when the accident occurred. If, at this time,
the extraction is not more easy, and yet the pain continues, the
root must be removed without delay.
Bruising and tearing of the Gams. — Sympatlietic Lesions of
various kinds. — Bruising of the gums is the inevitable result
of the action of all those instruments which make a fulcrum of
the alveolus, such as the key of Garengeot and the pelican ; and
tearing of this tissue is a common consequence of a rupture of
the alveolus. If the key is used, that part of the gum, only, cor-
responding to the extracted tooth, is liable to be bruised or divi-
ded, if, on the contrary, the pelican is employed, bruising of
the gums of the teeth, adjacent to the one to be extracted, upon
which it is necessary to let it rest, and tearing off the gum of
the extracted tooth is liable to take place.
The question now presents itself, as some practitioners, and
among them Malgaigne* advise, when it is perceived that the
gum is being torn, should the extraction of the tooth be completed
as quickly as possible? We are not of this opinion, for in opera-
ting with rapidity a much larger portion of the gum is liable to
be removed than would otherwise occur. It is rimch better, we
•* Ouvrage cite, p. 115.
OR MECHANICAL DENTISTRY, 347
think, to use the gum lancet, and Umit, by an incision with the
blade, the portion which should be sacrificed. The self-love of
the operator, may thereby suffer, but it is his conscientious duty
to pursue this course.
However serious the disorder which follows either of these
accidents, may appear, at first sight, in most cases there is no
very bad result to be apprehended. The use of Cologne water
or any similar article which is commonly given to patients, to
rinse the mouth immediately after the extraction of teeth, gen-
erally, is almost always sufficient to effect the resolution of bruis-
ed gums, or the retraction of the divided parts. If inflammation
of the parts is threatened, it is necessary to attempt to prevent it,
and if this is not possible, to combat it by the appropriate means
which we have indicated in many portions of this treatise. As
the disorders produced by this cause are ordinarily local, they are
generally easily managed. But sometimes the neighboring
parts, as the lymphatic glands of the neck, the sublingual and
maxillary glands, and even the eyes and the mucous membrane
which lines the pharynx, and the nasal fossa, are affected. A
young man once applied to us, to have extracted one of the first
molars of the upper jaw ; he was affected with lachrymal fistula,
resulting from the obliteration of the nasal canal, which, he
assured us, occurred in a few days after the removal of thecanine
tooth next to the small molar we extracted, and corresponding
with the diseased eye. An examination of the remaining eye-
tooth, led us to believe that the root of this tooth, also, was too
long to allow of its removal without the production of some
disorder.
To the accidents above enumerated, which may happen to the
soft parts adjacent to the teeth, may be added : shocks to some of
the branches of the inferior dental nerve, besides those immediate-
ly belonging to the extracted tooth ; from which paralysis of the
lip may result. A case in point is found in the works of Sir
Charles Bell ; it is reported by M. Jobert, as follows:* "A man
for whom had been extracted a molar tooth of the inferior jaw,
whenever he put a glass of water to his lips, experienced a sen-
* Ouvrage cile, tome 1, p. 186.
348 OPERATIVE MEDICINE AND PROSTHESIS,
sation as if the glass were broken, when he could readily see
that the impression was erroneous. This phenomenon was ac-
counted for by supposing that the man had lost the sensibility of
one-half his hp although it still retained its power of motion.
After the extraction of the tooth he was unconscious of the
presence of any substance coming in contact with the paralysed
lip. Charles Bell attributed this paralysation to some injury of
the nerve passing through the dental foramen, which as is well
known is a branch of the inferior dental nerve.
We are inclined to think, too, that the deafness often result-
ing from the extraction of certain teeth, is caused by a lesion of
the maxillary nerve, which, it is known, communicates by some
branches, with the internal ear. We knew of a man, in the
prime of life, who had one of the first large molars of the infe-
rior jaw, extracted ; the operation was difficult in consequence
of the abnormal conformation of the roots, and a part of the al-
veolar wall was broken. Some hours after the extraction of the
tooth he experienced a humming in the ear, and in less than
fifteen days he lost entirely the faculty of hearing on that side.
As the man was of a plethoric habit, the physician, whom he
consulted, did not for a moment suppose it was any thing more
than a congestion of the lining membrane of the cavity of the
tympanum, propagated along the Eustachian tube ; he advised
bathing of the feet, revulsive purgatives, and afterwards, the ap-
plication of dry cups, and then scarifications of the nape of
the neck and the skin back of the ear. But all was useless, the
hearing on this side was gone entirely and without return.
What is still more extraordinary, the same man, after two years
had elapsed, was compelled to have the corresponding tooth of
the same jaw extracted, after having suffered horrible anguish
for a long time in the fear of a new misfortune ; the same
result ensued.
M. Toirac, has related a similar case in a brochuse, published
in 1829,* but as he became acquainted with it from the state-
ment of the patient, he has, consequently been able to present it
* Memoire sur les diverses especes des deviations, dent est susceptible la der-
niere molaire, et sur les accidents qui peuvent accompagner sa sortie.
OR MECHANICAL DENTISTRY. 349
only indirectly. He gives it as follows : In 181 9, I saw a man
attending the clinique of Professor Roux, of the Charite Hospi-
tal, who complained of deafness in the left ear, which had re-
sulted from the extraction of a second molar tooth of the same
side. Three months after, he returned and apprised us that he
had lost the use of the other ear in consequence of the extrac-
tion of the corresponding tooth. I know that in this patient,
of whom I have lost sight, each operation was followed by ex-
cessive inflammation.
These accidents have been observed by Monteggia,* who thus
alludes to them : "When the dental nerve is bruised or rup-
tured, spasms of the face and deafness, or paralysis of the mus-
cles of the inferior lip and chin, may ensue, in consequence of
the communications of this nerve with the portio dura of the
seventh pair." M. Bossi has observed the injurious conse-
quences of a lesion of the nerve, in fractures of the inferior jaw ;
he proposes to displace the fragments, and introduce a bistoury
to cut the dental cord.
Doctor Valleix also, in his treatise upon neuralgia, relates
many cases of trifacial neuralgia, which could be traced to no
other cause than the effects of the operation which now engages
our attention. "The first symptoms of this affection," says he,
"in a patient who had never before suffered from neuralgia,
developed themselves a quarter of an hour after the extraction
of a canine tooth, which was affected with simple odontalgia;
in this single case, we meet with a very evident occasional
cause of this disorder, showing that it proceeds not from caries^
but extraction of the tooth.f
In a treatise upon dental medicine, published in England, in
1823,+ we find a case of facial neuralgia, of which the transla-
tion is as follows : A young lady, living at Plymouth, was
brought to me by one of my friends, Ur. Mudge; she was about
eighteen years of age, and, about two years previously, had un-
dergone a serious operation. The right superior molar tooth
* Instituz Chirur., tome 5, p. 54.
t Traite des JVeuralp^ies ; 1 volume in 8vo, 1841, p. 145.
J A Practical and Domestic Treatise on the Diseases and Irregularities,
etc , chap, xviii, p. 80.
350 OPERATIVE MEDICINE AND PROSTHESIS,
having become painful, and given reason to believe that it would
injure the adjacent teeth, she desired to have it extracted. The
operation was performed by the family surgeon ; a large portion
of the maxillary bone was unfortunately fractured, and, having
been disengaged from the adherent gum with great difficulty,
the two adjacent large molars, the roots of which seemed to be
interlaced with each other, came away, with a large piece of
the bone. The young lady, who had a good constitution, was
restored to health by the attention of Drs. Mudge and Gaskyne,
but, unfortunately, the result of the accident was a gradual con-
traction of the muscles of the cheek, under the eye, which
caused a disagreeable deformity of this part of the features."
Besides the various accidents which may result from the ex-
traction of the teeth, there are others, which may be the conse-
quence of the improper application of the instrument, which,
instead of affecting the tooth itself, produces some injury of the
adjacent parts ; Lecourtois* cites an instance of a dentist, who,
in making use of the davier, tore away a large portion of the
inner part of the cheek ; and of a surgeon who, in extracting a
stump with the punch, wounded the sublingual artery, thereby
causing a very serious hasmorrhage. The first accident is very
liable to occur to practitioners who are unacquainted with the
use of the pied-de-biche.
Denudation and Fracture of the Alveolus. — What we have
said with regard to the mode of action of the various kinds of
instruments used for the extraction of the teeth, will make it
plain to every one, that accidents of the two kinds specified
above, will be of common occurrence with operators who
almost exclusively make application of the key of Garengeot
and the pelican ; and what we know of the form of certain roots,
shows, too, that no instrument is sufficiently perfect to effect
their extraction without some injury of the alveolus.
When simple denudation of the alveolus occurs, it is rarely
that any serious consequences ensue, the cicatrization of the
gum is soon effected. But when the alveolus is fractured, and
a fragment of any considerable size has come away with the
* Le Dentiste Oljservateur, ou Recueil d^ Observations, in 12, Paris, 1775.
OR MECHANICAL DENTISTRY. 351
tooth, inflammation almost always supervenes, and this may be
SLifRcienlly serious to confine the patient to his bed. It may
be readily conceived, when this accident does occur, that ad-
dress must be used promptly, to detach the fragments of bone
from the tooth, before showing it to the patient, who would be
alarmed by it, and judge unfavorably of the operator ; but if
the adherence of the alveolus to the tooth is so great as to form
true anchylosis,* so that the patient can be made to understand
it, it is better, without circumlocution, to explain to him that
the obstacles to its perfect extraction were in this adhesion, and
not in the manner of operating.
The fragments of the fractured alveolus do not always, how-
ever, come away with the tooth. If these fragments are very
large, they may be attached to large portions of the gum ; it is
necessary, in such case, when it can be done, to separate them;
for, in tearing away the piece or pieces, a large portion of the
gum, covering uninjured parts, is also liable to be removed, an
accident which might occasion exfoliations more or less con-
siderable. There are cases, however, in which it is impossible
to effect this separation ; as when a large mass of the alveolus
is adherent to the root in its whole length, or is fractured, and
comes away with it, as we have shown. This often happens
with the last large molars, particularly of the superior jaw, where
it is always difficult to operate, either to luxate the teeth, or to
separate the gums, whether the operator is contented simply to
turn them out of their sockets, or to detach them with a cutting
instrument.
In the latter circumstance the operator will require all his
coolness, for the patient, giving way to the pain, loses patience
and complicates and prolongs the operation by his movements.
He should hasten to terminate it, the forceps with which he
seizes the luxated tooth, will enable him to make a lateral move-
ment in drawing it, and will tear the gum as little as possible
at least if he is operating upon a patient not sufficiently docile,
to permit him to make the resection with a gum lancet. This
" See our fourth page, where it will be been what is meant by an adhe-
rent tooth.
352 OPERATIVE MEDICINE AND PROSTHESIS,
loss of substance has, rarely, injurious consequences, which can
give reason to dread these accidents which may occur to com-
pUcate the operation of extraction.*
The slight importance, generally, of these accidents does not
render it less prudent to advise persons who are the subjects of
them to avoid placing themselves in circumstances which may
have a tendency to aggravate their results. Such as exposure
to severe cold, and more particularly, sitting in a draught of air.
There are many facts in our possession which prove that this
precept is not one of those unimportant recommendations, which
are often insisted upon to give more importance to the operation
performed, but is one which experience and reason demonstrates
it would be wrong to neglect. We, here, present one of these
facts :
In 1837, a rich farmer, in the environs of Paris, suffering from
caries of the second large molar of the inferior jaw, applied to
the physician, in his vicinity to have it extracted. The opera-
tion was performed, as may be suspected, with the key of Garen-
geot, a favorite instrument with surgeons who think of their
own convenience, more than they do of the good of the patient.
The pain experienced was violent, but the patient never having
had a tooth extracted before, did not suppose he suffered more
than is usual, and attaching no particular importance to his
case, set out the same day upon a journey of many leagues, in
an open carriage exposed to wind and rain. On reaching his
destination, he perceived his cheek swelling, and felt the ap-
proaches of fever to such a degree that he was compelled to take
his bed ; the next day the sweUing of the cheek, which was
at first confined to the region corresponding to the part upon
which the operation had been performed, had extended to the
whole of the side of the cheek, and, either because the inflam-
mation had extended to the skin of the scalp, and thence to the
dura mater, or because the brain became affected in consequence
of the excessive pain, delirium supervened. The physician
who extracted the tooth was sent for, and by a copius bleeding
» See what we have already said, in relation to fractures ia the pathologi-
cal part of our work.
OR MECHANICAL DENTISTRY. 353
from the arm, the application of opiate cataplasms to the affected
cheek, and frequent sinapised foot-baths, succeeded in arresting
the progress of symptoms which, if left to themselves, would in-
fallibly have terminated fatally. The cheek, however, remain-
ed swollen and painful for more than a month. Some persons
persuaded the patient that the continuation of these symptoms
might proceed from some portion of the root of the tooth still re-
maining in the socket, and he determined to consult us with
regard to it. Having attentively examined the place, from
which the tooth was removed, we found, not a portion of the
root, but, a long fragment, which had formed the anterior wall
of the alveolus and which had been fractured. The eliminato-
ry process which its presence had caused, having sufficiently-
detached it from the subjacent parts, we shook it slightly for
several days in succession, and, at last, removed it without any-
serious consequences.
The consequences of disorders brought on by the extraction
of teeth under the circumstances of which we have spoken,
may, indeed, have a termination infinitely more serious ; some-
times we have known death to result, as is shown by the follow-
ing case which we take from the English treatise, from which
we extracted the account of the case in another place.
"A merchant of Plymouth, travelling on business, stopped at
Kingsbridge, Devonshire. Whilst he was tying his horse he
was suddenly attacked with a violent tooth-ache. The land-
lord of the hotel, at which he stopped, told him that a young
man, in the employ of the druggist of the place, had been very
successful in the extraction of teeth, and the pain increasing, he
called upon the young surgeon and requested him to remove the
offending tooth. The latter, without examining the condition of
the tooth, or the circumstances of the traveller, had immediate
recourse to his instrument, which was the only one he possessed
and the best that could be found in the country — he placed the
patient on the ground and operated with violence. The affected
tooth was the first large inferior molar, to which, when it was
removed, a large portion of the alveolus adhered. The travel-
ler continued his journey without having been advised to take
those precautions which his situation demanded : he had about
45
354 OPERATIVE MEDICINE AND PROSTHESIS,
seven leagues to travel on horseback, and the weather was very
wet and stormy. Shortly after he started, the loss of blood was
so considerable that he was compelled to stop at a tavern, which
he found on his way, to procure a litde brandy with which he
rinsed his mouth and which somewhat palliated the painful
symptoms. He then continued on his way and reached home
at about half past nine in the evening. His jaws and head were
considerably numbed with cold, and nuich swollen, in addition
to this, symptoms of fever were present and the jaws were much
stiffened. The next day a physician was called in. At this time
all the alarming symptoms increased in intensity, and there was
apprehension that a spasmodic occlusion of the jaws and even
gangrene would supervene. The condition of the patient, in
the short space of twenty-four hours became quite alarming, and
the efforts of the physician were unavailing ; at the age of
thirty-two years, with a robust and healthy frame, this patient
died the sixteenth day after the extraction of the tooth."
Here terminates all that relates directly to the precautions
which we regard as necessary to be observed : but the close of
this case conveys a precept relating to the unnecessary extraction
of teeth, which is too important to be omitted. "The widow
of the deceased, who related to us the particulars of this unfor-
tunate affair, showed us the tooth, which she had found in the
vest pocket of her husband. On examination, we found that it
was very slightly decayed ; there was a small cavity on the
grinding surface, into which a small hard substance had been
pressed, causing, doubtless, the pain which he experienced in
dismounting from his horse at Kingsbridge. If this substance
had been removed from the cavity, and a small point of the
crown of the opposite superior molar pressing upon it had been
filed away, the pain might probably have been relieved by ap-
plying a little spirit to the part, and in place of extracting it, the
man and the tooth would probably been in existence till the
present day."
HcBmorrhage. — When the extraction of a tooth has been suc-
cessfully and properly effected, the flow of blood which follows
is almost always spontaneously arrested. In the majority of
cases, it is not only not necessary to arrest this bleeding suddenly.
OR MECHANICAL DENTISTRY. 355
but it is important that it should be favored, as it reheves the
turgid vessels of the gums and prevents subsequent inflamma-
tion. Sometimes, unfortunately, this flow of blood, trifling at
first, continues and increases in quantity till excessive hasmor-
rhage ensues. This result, which may become of more alarm-
ing character, than any which ordinarily follows the extraction
of a tooth, is less apt to be caused by the simple extraction of
the tooth itself than by the various accidents which we have
been engaged in speciying ;* it may even result in the death of
the patient, as will be seen from the case which we cite below;
many cases of a similar character have already been recorded
by writers upon our science.f
If haemorrhage proceeds from one of the sockets of the front,
and especially of the teeth of the lower jaw, it is generally quite
easy to arrest it. To accomplish this purpose it is sufficient to
introduce into the bleeding cavity, a piece of cotton or a
substance of a similar character, saturated with some styptic,
and force it down with a plugging instrument. Success may
also be readily obtained by filling the bleeding cavity with soft
wax, and pressing it firmly in its place by closing the jaws.
This means of arresting haemorrhage is especially useful when
it proceeds from the upper jaw, as by entering into all the an-
fractuosities of the alveolus, it fills it completely and retains it-
self in its place. A surgeon furnishes a case in the transactions
of the Royal Academy of Surgery, in which this means was re-
sorted to.J
"Having attempted twice, fruitlessly, to arrest a haemorrhage
with pledgets of cotton, saturated with Rabel water, the gen-
eral principle applicable to the case occurred to him ; first of all,
fearing that fragments of bone might be the obstacle, he examin-
ed the condition of the parts and discovered a portion of tartar,
which he removed from the socket, he then employed a plug of
soft wax, which he forced down with address, in all the alveo-
* Calsus regarded excessive haemorrhage as an invariable sign of fracture
of the alveolar socket, and even of the maxillary bone.
t See Cardan, De Causis et Sii^nix Moboruni, page l.'jS. — Plater, lib. iv,
case 35. — S. H. De Virgiliis Biblioth. C'/iirMrg-. page782,ex. J. D. ScHi.iTtNo.
J See these transactions in 12, tome ix. p. 237.
356 OPERATIVE MEDICIME AND PROSTHESIS,
lar cavities, thus bringing pressure to bear upon the mouths of
all the arterial branches. This means was followed by the most
happy success, and thus was saved the life of a man already
much weakened by loss of blood and threatened with approach-
ing death."
But there are other circumstances under which a hasmorrhage
of this character is infinitely more difficult to arrest,.as, for in-
stance, when it proceeds from the socket of a molar tooth, and
especially the wisdom tooth of theupper jaw, when the remain-
ing molar teeth are in their places ; when the roots of the ex-
tracted tooth show that the cavities are very deep ; when the sock-
et has been fractured, with loss of substance and the gum torn ;
when the gums were engorged with blood, before the operation,
and when the patient presents those characteristics of scorbutic
cachexia, which we have described in another place ; in this
last case, indeed, the haemorrhage may return, after having once
been arrested, as the slightest cause is sufficient to set the vessels
bleeding again. In order to arrest a haemorrhage, complicated
by any of the above named circumstances, the following steps
must be taken ; in the first place, care must be taken to ascertain
the exact place from which the blood flows, and to assist the ac-
complishment of this purpose, the coajulated blood around the
open vessels, or buried in the depths of the socket, must be re-
moved; then pledgets of cotton dipped in vinegar, or in some of
those hemostatic wa/ers, which have made so much noise of late,
and of which the useful ingredient is alum (sulphate of alum-
ine,) should be forced down into the bleeding socket ; a lateral
compress should then be formed by placing between the gum
and cheeks, pieces of cotton, thick and flattened so that strong
pressure on the gums can be made; the two jaws should then
be brought together so that the lower may exercise pressure
upon the upper ; care should be taken to fill any space which
may be left opposite to the bleeding socket, in consequence of a
loss of teeth. Sometimes it may be useful to apply a compress
upon the face under the cheek bone, as this will bring pressure
to bear upon the base of the ajiparatus ; the jaws should be re-
tained closed by means of a bandage passed around the head
and chin. This apparatus should be kept in place at least three
OR MECHANICAL DENTISTRY. 357
or four days, if not longer. The cotton should only be removed
and renewed, when it is necessary to dress the wound.
Some practitioners find it more certain, or at least more expe-
ditious, to have recourse to cauterization, performed either with
the red-hot iron or with a concentrated acid.
We will not repeat what we have said, elsewhere, of the in-
convenience and even danger of this remedy, (especially the
last,) the employment of which requires skill and the greatest
circumspection. We will be satisfied with observing, that the
cautery is an extreme remedy and is only applicable to those
cases where the exact point of the alveolus from which the blood
flows can be seen, and the jet of blood renders apparent the
mouth of the vessel which furnishes it ; it would be entirely
irrational to resort to it when the hasmorrhage proceeds from the
lacerated gum or from the alveolo-dental membrane ; it is best
then to use compression ; this means, however, is not infallible
as is proven by the following case taken from an English jour-
nal, the "London Medical Gazette."*
A gentleman of middle age, quite robust, had the wisdom
tooth of the right side extracted on the 19th December, 1841.
The extraction was made with a pair of forceps of the kind
generally used for removing the temporary teeth. The bleeding
was not remarkable, and was readily arrested by means of a
compress upon the alveolus assisted with cotton dipped in cam-
phorated brandy. At half-past four in the evening the bleed-
ing returned ; it emanated from the cavity of the anterior root
in great abundance, and in all probability from the alveolo-dental
membrane, and not from the central artery of the pulp, as no jet
could be discovered. The compress already applied was remov-
ed and the cavity cleaned out, washed, a new compress applied,
and carried down more forcibly than the first, by means of a
curved instrument; above the compress, a plug was applied,
which was strongly compressed between the two jaws — a band-
age kept the jaws together. The bleeding was arrested for the
time, but re-appeared ; it was again arrested and again returned,
and thus it continned for three weeks, night and day. At the
* February, 1842.
358 OPERATIVE MEDICINE AND PROSTHESIS,
end of this time the patient had became so weak that he died
from anemia, in spite of the effort of many physicians." This
account is followed by a detail of the means to which they had
recourse.
Although the means we have indicated are very rational, we
think they might, very often, be substituted by a long continued
application of the finger and thumb to the alveolus filled with
cotton ; in the same manner that the bleeding of a leech-bite is
stopped by pinching up the skin. One of us was called in to
a case of similar character, at Varsovre; the patient was the
wife of a Jew banker, and had been abandoned by the dentist.
We succeeded in arresting the haemorrhage by holding the fin-
ger for a long time applied to the bleeding alveolus, and com-
pressing, from time to time, the whole thickness of the jaw,
down to the level of the alveolus. This mode of compression
was known to Van Swieten,* who declared that he had wit-
nessed the most happy results from its use.
It must not be supposed that the teeth most firmly implanted
in their sockets are the only ones the extraction of which is
likely to be followed by haemorrhage. Valeriolaf mentions the
case of an old woman, for whom he extracted a carious tooth,
with his fingers and without effort, who experienced a haemor-
rhage, which continued three days before it was arrested ; be-
fore this time, however, she did not call in the assistance of any
one. The cases, unfortunately, are not very rare. We recol-
lect the case of a man, thirty-five years of age, for whom, with
the forceps, and with great ease, we extracted a first superior
molar, deeply decayed, and for a long time loose ; hardly was
the tooth out of the socket, when great haemorrhage ensued, and
the ordinary simple means having failed, we were obliged to
apply a compress.
It is important to know that haemorrhage after the extraction
of teeth does not occur immediately after the performance of the
operation. We have seen it occur after the lapse of seven, eight
and twelve hours, and not be less alarming on that account.
* Comment, in ^plwr., Boerhavii, § 248.
^Memoir de VJlcad. Roy. de Chirtirgie, tome vii, p. 40.
OR MECHANICAL DENTISTRY. 359
Here we give a case, in proof of what we say, in addition to
that which we extracted from the English journal.
In 1833 or '4, we extracted a first inferior molar for a young
man, of about twenty-four years of age. The operation, without
having been very painful, was difficult, in consequence of a
backward curvature of one of the roots, and a portion of the al-
veolus was necessarily broken. The quantity of blood which
flowed from the alveolus, during the quarter of an hour that the
young man remained in our ofiice, was not more than usual ;
the gum was uninjured, and we saw no indication of a scorbu-
tic constitution. In the middle of the night, fifteen or sixteen
hours after the operation, the mother of the young man came
in great alarm, to beg us to come to him, as, ever since evening,
he had been losing blood from his mouth in great quantity.
We found him in his bed, literally bathed in blood. After get-
ting him to rise, we examined the alveolus, by removing the
coagulated blood, and, perceiving no arterial jet, we applied
to it a number of bits of cotton, saturated with vinegar. The
blood continuing to flow, we placed his feet in sinapised water,
and ordered him to remain in a standing position ; we then re-
placed the cotton saturated with vinegar, with others which"
were sprinkled with powdered alum. The patient fainted, but
soon recovered, and the blood ceased permanently to flow.
Three or four days after, he called upon us, having already re-
covered from the weakness occasioned by the loss of blood.
Injury to the Adjoining Teeth, and their Replacement. — 1st.
The loosening, luxation and even complete fracture of the teeth
adjoining the one we wish to extract, or which has been extract-
ed, are accidents which may occur in many cases — for instance,
when the patient displaces the instrument, by seizing the hand
of the operator ; when the hook is too large, and encroaches
upon a tooth next to that which is to be extracted, to which its
action should be confined ; when it is not placed precisely in
the middle of the tooth ; when it has been held obliquely, and
when, in the luxation, it has encroached upon its neighbors;
when the adjoining teeth are weaker than the one to be extract-
ed; and, their alveoli fractured, at the same time leaving them
denuded ; when the pelican is used for the purpose of extracting
360 OPERATIVE MEDICINE AND PROSTHESIS,
the large molars, and a fulcrum is made of the weaker small
molars; finally, when the operator mistakes the seat of the dis-
ease, and extracts a sound tooth for the diseased one ; or, in
attempting to extract one, two, which are united, as in the case
related by Fauchard,* are removed
Sometimes, as is most commonly the case, the accident is
confined to a single tooth ; sometimes, on the contrary, two are
subjects of it, as in a case we saw about a year ago, in which
an attempt was made with the key of Garengeot, constructed
with the pretended improvement of Maury, a fulcrum being
made of the two small molars in front of it. Sometimes we
have known even three teeth to be forced out with the one
which was to be extracted. These accidents, the last particu-
larly, were of much more frequent occurrence at that period
when the pelican principally was used in the extraction of teeth,
with which instrument the slightest want of skill was liable to
produce disasters of the gravest character ; this is proved by the
amusing but unfortunate case related by Ambrose Pare, of the
servant of a dentist of Orleans, who, in attempting to extract
teeth, like his master, with this instrument , extracted, besides
the bad, three good ones.f
The operator should earnestly endeavor to avoid the causes
of these various accidents. He will almost always succeed in
this, by adhering to the rules which we have recommended as
being the best in theory and practice. If, however, contrary to
expectation, any one of them should happen to him, he must
hold himself ready to make the best of it. If a tooth is simply
loosened, he must direct the patient to avoid using the jaw for
several days, so that it may recover its usual firmness ; if it is
completely luxated, he should replace it, and keep it fixed, as
we have directed, when treating elsewhere of luxation ; means
*Ouvrage cite, tome i, p. 342.
t "But in place of extracting the bad tooth of the poor villager, he re-
moved three good ones. Experiencing extreme pain, and seeing three of
his teeth out of his mouth, he began to cry out against the Picard, who, in
order to silence him, said to him, he had better be quiet, for if his master
came in, he would make him pay for three teeth instead of one." — CEuwei
d* Ambrose Pare, livre xvi, chap. 27.
OR MECHANICAL DENTISTRY. 361
known to Hippocrates, who advises, for the purpose, threads of
gold or silk.* If, on the other hand, it is fractured, the operator
is to act as in any other case of ordinary fracture.
Besides the three kinds of injuries which the teeth adjacent
to the one we are desirous of extracting are likely to suffer, (viz.
loosening, luxation and fracture,) there may yet occur, as we
have already intimated, one of a more serious character,?, e. their
complete extraction. The only method of procedure, in such
case, is immediately to replace the tooth which has been acci-
dentally extracted, and keep it in place, in the same way as
with a luxated tooth. We advise this, for the purpose of reas-
suring the patient, and to make the accidant appear less serious
than in the conviction that a tooth in this situation will recover
its original firmness, as appears to be believed by Maury, M. M.
Lefoulon, Delabarre and many other modern authors.
A person named Dupont, in a pamphlet, published in 1633,
entitled "A Remedy for Tooth-ache," was the first who es-
tablished as a rule the immediate replacement, of an extracted
tooth in its socket, and he was of opinion that it would not be
long before it contracted new adhesions, to the walls of the al-
veolus. Fauchard was fully of the same opinion, as is proved
by the following sentence: "It should not be unknown that the
teeth after having been extracted, will again become firm in
their sockets, if they are immediately replaced." Dionic and
Verdum, however, who were his cotemporaries, maintained and
demonstrated the contrary. Finally, Monton,t in 1786, en-
deavored to give new credit to this opinion of Fauchard, which
many dentists, even M. Duval, dared not formally oppose ; this
practice was adopted by Benjamin Bell on the faith of Hunter
and Callisen, as is proved by the quotation which we have pre-
sented on another page, from this author, as also one which we
will make presently.
Our own experience has demonstrated to us, many times, that
* This is the only case in which Hippocrates has specified the use of these
two species ofligature, although they were evidently known before him, as
we will demonstrate in the chapter devoted to dental prosthesis.
t Essai df OdonloUchnie.
46
362 OPERATIVE MEDICINE AND PROSTHESIS,
teeth thus replaced, act as nothing else than foreign bodies,
which have no other advantage than to fit down exactly into the
socket ; but it is not long before they are lost by decomposition
or the absorption of their roots. Often, indeed, before this de-
composition is effected, they are the cause not only of disagreea-
ble fistules, difficult to cure even after the extraction of the
teeth, but, also, as is attested by Richerand, they may occasion
other serious affections, such as caries of the jaw, obstinate odon-
talgia, and even convulsions which have only been relieved by
their final extraction,* The following case proves the justness
of our opinion.
In 1820, Dr. Londe, then a member of the Royal Academy of
Medicine, having suffered for sometime, great pain, caused by a
decayed first large molar of the lower jaw, requested a young
physician, one of his friends, to extract it for him. The physi-
cian, used the key ofGarengeot, and operated in such a manner
as to remove with the diseased tooth, the last small molar, with
a considerable portion of the alveolus attached — an accident
very common when the instrument is used by the inexperienced.
The first movement of M. Londe, was to replace the first large
molar which was still attached by the gum, and an hour after
he returned to its socket the small molar which, till then, had
remained lying upon the table. The pain which followed the
replacement of these teeth was supportable during the day, but,
at night, in consequence of the pressure upon them by the an-
tagonist teeth, caused by an involuntary contraction of the zy-
gomatic temporal and great pterygoidean muscles, it became
very intense. M. Duval, whom M. Londe informed of the acci-
dent, advised him to keep the jaws slightly separated by a wood-
en wedge, this afforded relief. The inflammatory swelling of
the gums seemed to be entirely dissipated on the eighth day, but
the pain continued and M. Londe, guided in theory by his know-
ledge of physiology, and in practice by the authority of Gariot,
who denied the possibility not only of their acquiring a positive
adhesion but even a satisfactory degree of firmness, went again
to have these teeth extracted, without the interference of M. Du-
* JVosogruphie Cliifurgicale, tome ii, page 519.
OR MKCHANICAL DENTISTRY. 363
val, who advised him to retain them in his mouth. The pain
indeed diminished and two years after, these teeth seemed to
have acquired the greatest degree of firmness.
Here ends the relation of M. Londe,* who declares elsewhere
that he was well convinced that these teeth were entirely devoid
of vitality ; a declaration so much the more important as it was
not long before these teeth were lost, contrary to the hopes
which were at first excited— this we are authorised to state by
this honorable physician. On the same day that this case was
presented to the Academy, the celebrated Dupuytren handed in
the following note which we copy from the original :
"Five years ago, a young physician, in order to give room to
the second teeth, extracted a number of the deciduous teeth of
a very young child ; amongst the rest he extracted by mistake
a permanent, instead of a deciduous tooth. The error, discover-
ed an hour after its occurrence, seemed irreparable. Three hours
had elapsed when I saw the child. I directed the tooth to be
replaced in its socket; this was done, it was pressed down firm-
ly and kept in place by a bringing together of the two jaws. It
has remained in place, since that time without having caused
pain or undergone any change in color or alteration of its natu-
ral appearance. It answers the same purpose as the rest ; it
appears to possess an equal degree of vitality, or at least it does
not appear to differ from them in any manner.
„ ^„ Dupuytren.
May 23, lb20."
We do not hesitate to say, in spite of this authority, that if M.
Delabarre had again seen, six or seven years after the accident,
this child, which had given him so favorable opinion of the re-
placement of teeth in their alveoli, he would have agreed with
M. Londe, and would not, contrary to all physiological probabili-
ties, have stated that "the teeth extracted from their sockets and
replaced a moment after became perfectly firm, because they
contract adhesion, very intimate and probably vital, with the
surrounding parts"t which, according to his own avowal, did not
» Voyez le Journal Universal des Sciences Medicales, caluer de juin, lb22.
t TVaite de la pari. Mecaniq, de VArt de Chirurgien Dcntisle, etc, tome ii,
page 322. Voyez Jlwsi la note qui est an has de cede pa<re.
364 OPERATIVE MEDICINE AND PROSTHESIS,
happen in the case in which he attempted the proof in his own
person.
In short with regard to the replacement of a tooth which has
been removed from its socket, by accident or otherwise, we will
say : according to the present state of physiological knowledge,
we cannot see that a tooth once removed from its socket and
replaced, is anything more than a foreign body perfectly adapted
in form to its situation and by that means remaining in juxta-
position. If at the time, when circumstances render neces-
sary the extraction of teeth thus replaced, some appearance of
blood-vessels is discovered towards the extremity of the root, or
even in the dental canal, it is, in our opinion, no proof that the
circulation between the root and bottom of the socket is re-es-
tablished ; it rather induces us to believe that the alveolo-dental
membrane may have granulated, and that some of the granula-
tions may have been thrown into the dental canal. The success
which has been obtained by modern surgery, in anto-plastic
operations, may, perhaps, furnish ground to some dentists to main-
tain an opinion opposite to that which we have endeavored to
develope and sustain, but which we nevertheless persist in.
However, this may be, when these teeth are replaced and be-
come very loose, some persons, especially when they are in the
lower jaw, are in the habit of removing them at night and re-
placing them in the day-time, keeping them in position by
closing the jaws upon them. This is a very bad practice, be-
cause the contest which is established between the alveolus, in
which there is a tendency to close, and the tooth which acts
mechanically in keeping it open, may give rise to a chronic in-
flammation which is liable to degenerate into a carcenomatous
affection. Many cases, and amongst others, one furnished by a
venerable ecclesiastic of the environs of Paris, show us that
this fear is well grounded.
The diverse considerations and above all, the case of Londe,
to which we might add a number exactly similar, proves what
we might think of this operation which, under the name of
dental transplantation^ consist in extracting, for a piece of sil-
ver, a tooth from the mouth of a young and healthy individual
and placing it in the alveolus of the purchaser who had just
OR MECHANICAL DENTISTRY. 365
lost one of the same kind. A barbarous operation, which we
flatter ourselves never to have practiced ; an immoral procedure,
which reproves the manners of the day, and the impossibility of
finding two teeth whose roots are exactly of the same size, proves
the absurdity of attempting it, if its execution does not find a
sufficient obstacle in our penal code, which forbids all species of
mutilations.
As inhuman and impossible as it is in its final result, the trans-
plantation of a tooth from one mouth to another has, however,
for a long time been practiced in France ; it was known here as
long ago as the time of Ambrose Pare, who speaks of it thus :
"A man worthy of being believed, has affirmed to me that a
princess having had a tooth extracted from her own mouth had
it replaced with another taken from the mouth of one of her
maids; and which, sometime after, she used as she had done the
one she had lost;" but to prevent being too hasty, he adds;
"1 have heard of this case but not seen it." But what is re-
markable, is, that it has not been half an age since English sur-
geons classed it among regular operations, as Benjamin Bell,
distinctly asserts, who not only describes it in all its details, but
who goes so far as to desire "that he might always have a num-
ber of persons ready to furnish their teeth, in order that dentists
could always find them of the right size and shape ;" our con-
freres on the other side have little to envy us, it is true, in this re-
spect, for Maury, declares that he had practiced it upon two per-
sons in 1812.
Finally, we do not terminate that which concerns the injury
that some teeth may receive from the fact of the operation hav-
ing for its end the extraction of the adjoining ones, without
speaking of the possibility of removing with a diseased tooth a
healthy one, but which might adhere to it, and of the course to
pursue in a case where we might forsee the injury before com-
mitting it. We have said, that Fauchard related many instan-
ces of this kind. See the following case and his reflections
upon it : "In 1705, a reverend father recollect of the city of
Lude, in Anjou, came to me to have a large molar tooth extract-
ed. I examined his mouth ; I perceived that it was so much
decayed that no hold could be obtained upon it. Although I
366 OPERATIVE MEDICINE AND PROSTHESIS,
had seized with the instrument which I used, the tooth he
wished me to extract, f nevertheless removed two at once. I
beUeved at the moment that I had committed a great error ; but
I found that tooth which had followed the first was decayed as
much as the other, and that they were so adherent together and
united in such a manner by their roots that they formed nearly
one body. This, recollect, believing nevertheless that I was
deceived, had the curiosity to examine if that which I had said
was there. In order to convince ourselves better of the fact, we
endeavored in vain to separate the teeth with the blade of a
knife : we struck upon the blade with a stone and were only
able to separate them by breaking them in pieces."
This case suggested to Fauchard, some very wise reflections
which we will report here : He says, "upon this subject, we
often meet with difficulties in the extraction of teeth which we
cannot anticipate. If there is any way of avoiding the acci-
dents which are liable to occur, it is, with care and without pre-
cipitancy. It is necessary to be careful in the first movements
which we give to the tooth, and to closely observe the resist-
ance that is made to their first efforts ; particularly the effect
which it has upon the neighboring teeth. If these latter move,
we may infer from thence that the teeth touch in some place.
If the movement is very considerable there will be reason to be-
lieve that they are united together, and that they adhere to the
middle wall or to some other part of the alveolus. In such a
case it is necessary to proceed in the manner as we have fully
described. When the operator is well instructed, prudent, cir-
cumspect and ingenious, he will be able to avoid not only many
accidents, but, also, of inventing new methods of procedure,
from which the public may derive great advantage."
The cases of teeth adhering together by their roots are so
numerous that we often fear the accident here mentioned. It
is by conforming strictly to the precautions of Fauchard, that
we have many times been able to avoid it. As to the ad-
herence of the teeth by their crowns, of which the examples
are more rare, as it does not necessarily imply a union of their
roots, we may destroy it with a file, provided we redouble our
attention at the moment of the operation and decide correctly
OR MECHANICAL DEMTISTRY. 3t)7
which of the two teeth should be extracted. Five or six years
since we separated a large from a small molar, and extracted the
first without inflicting any injury upon the second. If the ad-
herence resist at the same time between the crown and the root
the operator, in destroying the first, will certainly have done all
which prudence demands of him ; that which might follow
from the union of the roots could not be imputed to want of
skill.
Partial Fractures of the Maxillary Bones.
Fractures which are the accidental results of extraction, are
generally confined to the teeth themselves or the alveolar parti-
tions; we have heretofore treated of them. We have, however,
seen many cases in which the body of the maxillary bone was
broken. Fox gives an example* of this kind, which we have
formerly reported of him, that of an individual who, wishing to
be freed from an inconvenient and painful wisdom tooth, had a
great portion of the inferior jaw removed with the tooth extracted
doubtless with an instrument having too large a crotchet. Du-
val gives similar examples.
We have also in our collection of pieces of pathological anato-
my; 1. An enormous sequestrum to which belong the two inci-
sors, the canine and the two small right molars, which we
removed from the lower jaw of a person twenty-eight years of
age, for whom we had extracted, without the necessary precau-
tion, the first large right molar ; 2. A canine, the extraction of
which was effected at the expense of the anterior table of the
inferior maxillary, more than an inch and two lines in width,
and double the length ; 3. A first large molar to which adheres
all the part of the alveolar border vi^hich extends from the second
large molar to the canineof the same side, and having the traces
of the alveoli of this latter and of the two small molars which
had been removed for a long time, with a portion of the maxilla-
ry itself, nearly six lines in thickness.
What is very remarkable is, that the teeth implanted in these
* Work quoted, plate 8, figure 8.
368 OPERATIVE MEDICINE AND PROSTHESIS,
two latter pieces are removed and replaced in their alveoli with
a facility which shows that the accident was not attributable to
malformation of their roots, but the frequency of its occurrence is
owing altogether to the awkwardness of the operator. Further-
more, we have had in our possession an enormous portion of the
inferior maxillary of the left side, which a negotiator of Paris had
the kindness to show to us ; he declared to us thatit was the result
of the extraction of a molar made with the key, and he had the
courage to facilitate its removal by the continual loosening of it
to which he submitted.
Among the many deplorable instances of fractures of the lower
jaw, which have resulted from the extraction of teeth, we will
quote the one, of which Dr. Fournier, of whom we have spoken
in another place, has been the subject, which he thus relates,
after having spoken of his broken teeth. "Four years before, a
dentist of the province, profoundly ignorant of the most elemen-
tary principles of his art, being requested to remove for me the
opposite tooth of the same jaw, having the same faulty conforma-
tion, (exostosis of the root,) he employed vain efforts for more
than a minute ; finally, he fractures the alveoli and a part of the
jaw, and gave up the operation without having removed the
tooth."
Finally, the following fact, related by Maury, furnishes an
idea of the disorders that may result from these fractures:
"Being in Calais in 1815, we bestowed some care upon a work-
man who had a portion of the lower jaw fractured in conse-
quence of the extraction of a large molar, which was done v/ith
a key having a right shank. The operation had been practised
from without inwardly^ and the surgeon was obliged, by the
disposition of the shank of the instrument which he employed,
to apply one of the angles of the bolster upon a neighboring
tooth ; and in consequence of which the tooth was broken and
the jaw fractured. It was nine months after this accident when
we were called upon. After examining the patient, whose
state even at this period, appeared to us very alarming ; we dis-
covered a considerable fracture of the inferior maxillary bone of
the right side, a fracture which had been necessarily produced
by the extraction of the tooth. The portion of the bone in
OR MECHANICAL DENTISTRY. 369
which the other teeth were implanted, from the angle of the
jaw to the canine tooth, was necrosed, and in acting as a foreign
body, caused mechanical irritation, (he wished doubtless to say :
determined mechanically an irritation,) which the presence of
several pieces of bone that presented themselves from time to time
from the fistulous orifice, considerably increased. A splinter
of bone terminating in a point, an inch and three lines in length
and eight lines in width, pressing upon the external part of the
canine tooth.
Such was the conditon of the patient when I proposed to him
to have the loose splinters of bone removed. He willingly con-
sented, and after using the precaution to detach from the prin-
cipal sequestra, a considerable portion which was adherent to it,
we proceeded, not without some difficulty, to remove it. The
second portion of bone which remained, an inch and nine lines
in length, and eight lines in breadth, and occupying as the first,
all the right side of the jaw from which the teeth had been ex-
tracted, a few days after, with not less success. After this the
irritation, and consequently the inflammation ceased ; the parts
cicatrised in from fifteen to twenty days ; mastication then
became more easy, digestion was re-established, and in less than
three weeks the patient was entirely cured. After another voy-
age to England we had occasion to see him again ; he was
scarcely disfigured, although he had lost a large portion of the
right side of the maxillary bone, and the canine tooth corres-
ponding to the second large molar of the superior jaw.
When fractures of the alveoli of the superior jaw take place
they are generally complicated with fractures of the maxillary
sinus, and a laceration of its hning membrane ; the consequence
of this is, a discharge of viscid and purulent matter from it.
We have only had one case of this description, the subject was
a man from thirty to thirty-six years of age, who had had the
sinus opened in consequence of an awkward application of the
bolster of the key of Garengeot, employed for the extraction of
the second large left molar of the superior jaw.
This tooth, extracted outwardly, with violence, according to
the statement of the patient, with the right shank and naked
bolster, had drawn with it all the osseous portion forming the
47
370 OPERATIVE MEDICINE AND PROSTHESIS,
anterior wall of the alveolus which contained it. When the
patient presented himself to us, he was still suffering from the
accident, and had done nothing since then to prevent the intro-
duction, into the open cavity, of air, alimentary matter, and the
mucous fluid of the mouth. He wanted the two small and first
large molars. We advised him to have false teeth, mounted upon
a base of hippopotamus, with artificial gums, and exactly filling
the opening. This piece, fastened behind the third large mo-
lar, which was well developed, by means of a large and solid
crotchet, (clasp,) and in front to the canine, easily accomplishing
the double indication to be fulfilled : to stop up the opening of
the sinus, and to fill the space which the absence of the four
teeth, and a part of the alveolar border in which they were
implanted, had caused.
Highmore, who has given the best description of this cavity,
has given to it his name, and left upon record a description of a
case of accidental opening, sufficiently curious to render it wor-
thy of being repeated : "A lady having had the superior canine
tooth extracted, a portion of the maxillary bone was, at the same
time, brought away with it, leaving an opening, from which
habitually flowed a serous humor. Wishing to ascertain frq^n
whence this humor came, she introduced a stilet, and afterwards
a shaved quill, to the width of six fingers, which very much
frightened her, believing that she had touched the brain.
Highmore assured her, by showing her, in a skull, the cavity
in which the quill was introduced, and advised her to bear with
patience her afiliction."*
Such, also, is the case related by Hoffman, with this dif-
ference, however, that the fracture of the sinus had been oc-
casioned by the second large molar, and that he eased his
patient by filling this fistule, in order to prevent the intro-
duction of air, and, without doubt, to prevent the escape of the
mucusf.
The fractures of the maxillary bones themselves, as the result
of the extraction of teeth, are, fortunately, as rare as they are
* Corpus Humanum, Disquis. ant., caput J , liber 2.
t De Dentibus, eonim Morhis el Cura. In 40, Halce Magdeburgicce, 171 1,
page 29.
OR MECHANICAL DENTISTRY. 371
grievous. The course to be pursued in cases of this sort, must
necessarily be varied, in proportion to the size of the piece which
has been detached. If it is only a splinter of bone, or to specify
the case more distinctly, and to particularize the treatment, if
but a thin, straight piece, about an inch in length, especially of
the lower jaw, it will be necessary, in all cases, to remove it, for
this portion, too small to contain the elements of vitality neces-
sary to its reunion to the bone itself, forms not only an obstacle
to the nutrition of the teeth near it, and ultimately cause their
destruction, but would itself decay, and induce an elementary
suppuration, whose resorbtion would become troublesome, or
form fistules, whose aspect would be disagreeable.
"We well know," as M. Lisfranc judiciously observes, in his
able treatise on clinical surgery, "that when a bone mortifies in
the midst of its living tissue, it is insensibly absorbed, and ends,
sometimes, by completely disappearing itself;" but, from the great
vitality of the tissue, we may expect a great absorbing energy,
from which cannot be expected from the gums, which possess
little of this energy; as we think, it is always useful to remove
the splinters of the alveoli which result from extraction, espe-
cially at the moment when the gums, on being pressed, pass
from a bright to a violet red, or when the lightest pressure ex-
erted upon them, puts in action their mobility; for a still greater
reason, when we perceive, ;from slight pressure, that pus is
formed between the gums and bone.
The method of removing these fragments of bone, consists in
progressively loosening them, by gentle tractions exerted with
small forceps, then to completely remove them, when we have
reason to believe that their adherence is sufficiently destroyed
to prevent a painful laceration of the gum, or a troublesome
hffimorrhage. We may prevent inflammation by emollient ap-
plications, and assuage the pain by narcotic fomentations, ad-
ministered in the form of gargles. After the piece has been
removed, we should watch the healing of the parts to prevent
unnatural adhesions.
If the detached portion is greater than the remaining parts of
bone, it is necessary to attempt the union of it with the body of
the bone, by keeping it firmly fixed in its place, by means of a
372 OPERATIVE MEDICINE AND PROSTHESIS,
bandage, and only to remove it when it is impossible to accom-
plish this object.
In fine, as fractures of the maxillary bone, accidentally caused
by the extraction of teeth, may necessarily occasion injuries
proportioned to the extent of the osseous portion removed, the
precautions which we have said should follow a simple fracture
of the alveolar border, should be, for a still stronger reason,
taken when a portion of the maxillary bone itself is broken.
Complete FVacture of the Inferior Jaw.
We have heretofore treated of fractures of the maxillary bone
only in their relation to the extraction of teeth, consequently of
those fractures commencing in the alveolar border, and which
are common to both jaws. But the body of the inferior maxillary
is liable to be fractured completely across ; and although this
accident, from the fact that it is scarcely ever induced by an
operation of our specialty, must needs be strange to us, yet it is
no less important to be able to distinguish it, and to know with
exactness the principles upon which to base its treatment. In
effect, as it is nearly always the result of causes whose action is
extended to the teeth as well as the jaw, the intervention of the
dentist is necessarily called for, and it would be ridiculous if he
were not able, at the same time, to remedy the injury the teeth
sustain, and also the bone in which they are implanted ; we
think ourselves, then, obligated here to treat of it as briefly as
possible.
1st. The compactness of the inferior maxillary, the great mo-
bility and elasticity which its parabolical form necessarily gives
to it, will explain why entire fractures are so rare. This frac-
ture, ordinarily occasioned by blows or falls, offers, as it regards
its seat, important differences ; sometimes it attacks the body of
the bone itself, and then it has a seat in the symphysis, or from
this symphysis to the masseter, that is to say, even to the union
of the branches to the body; sometimes, on the contrary, it
attacks the branches, the condyles, the coronoid apophysis or
the alveolar border. As most other fractures, it may be either
vertical, transversal, oblique, simple, complicated, comminutivc,
OR MECHANICAL DENTISTRY. 373
single or double. Finally, it may exist at the same time upon
both sides, especially when it affects the body of the bone or
its condyles.
The causes which occasion this fracture act in two different
manners ;* in the first case, violence tends to destroy the curve
described by the bone, the solution of continuity will commence
with the osseous fibres of the lingual face ; the instances of
fractures produced by this mechanism are not rare. In the
second case, it results from a double pressure exerted upon the
two sides of the line, and increasing its curvature ; this fracture,
ordinarily simple, will commence with the fibres of the con-
vexity, or external fibres of the line.
The characteristics of this fracture are very easily determined.
"A blow, a fall," says Boyer,t "a difficulty of the movement of
the part in pronunciation and mastication, and more or less acute
pains, are some of the circumstances which cause it to be sus-
pected. But if, in placing the fingers along the inferior border
of the line, we find some points, either on one side, or all the
part, which are not on the circle with the rest ; or if, on exam-
ining the teeth, we perceive between them the same relation
that we observe between the different points of its base, we can-
not doubt the existence of this fracture.
"When it is double, and comprehends all the anterior part of
the jaw, the displacement and deformity are so considerable that
the slightest glance would observe it. We cannot detect the
fracture except by crepitation ; we then endeavor to make the
extremities of the fractured bone move one upon another, by
seizing the two parts of the jaw, and moving them in contrary
directions. The fracture of the neck of the condyle being
always accompanied by displacement, it is not difficult to detect
the fracture, at least when it is accompanied by considerable
swelling of the soft parts."
Let us add, that when the fi-acture is oblique, from above
downwards, and from before backwards, the displacement is
very easy ; it is on the contrary, when the obliquity is in an
* ViDAL, (de Cassis,) page 72.
t Treatise upon Surgical Diseases, vol. 5, p. 127.
374 OPERATIVE MEDICINE AND PROSTHESIS,
opposite direction, because the contraction of the masseter
presses the inferior fragments against the superior, and thus
renders displacement ahnost impossible. There is no displace-
ment when the fracture presses against one of the branches of
the bone, because the masseter muscle and the internal ptery-
goidean hold the fragments in their proper position. It is the
mobility and crepitation which reveals their existence. We ob-
tain these signs by taking hold of the branchof the bone within
the mouth, and its angle without, and producing these move-
ments. Finally, in all cases where displacement is well estab-
lished, it may nearly always be perceived by examining the
dental arch.
2. Fractures of the inferior jaw, whether they are simple or
compound, are easy to reduce. In order to do it, we place the
displaced part in height, and a little before, and upon the base
of the bone, in such a manner as to bring it back again upon a
level with the portion which remains in its natural position. It
is only by giving attention to the line which should form the
the base of the jaw, and observing if the dental arch is in its
natural state, that we can assure ourselves whether the reduc-
tion is well made. But it is difficult to maintain the reduced
fracture ; we cannot accomplish it without sustaining the infe-
rior jaw against the superior.
"The means which have been proposed for accomplishing this
important indication," says Sauson,* "are as numerous as those
which corresponds to the difficulty of effecting it. They vary
according as the fracture affects the body or other parts of the
maxillary bone, and as it is or is not accompanied by the dis-
placement of the fractured pieces. For fractures of the body of
the bone, without displacement, some surgeons employ a method
proposed by Hippocrates, and which consists in tying together,
with a thread of metal, the adjoining teeth of the fractured ex-
tremities ; we then bring the jaws together by means of a ban-
dage, called the sling of the chin.
But if the tendency to displacement is considerable, and in
« Dictionary of Medicine and Practical Surgery, vol. viii, page 473, article
Fractures.
OR MECHANICAL DENTISTRY. 375
the case of compound or oblique fractures, we are obliged to
have recourse to more efficient means. We have rejected the
leather and pasteboard splints of which Ambrose Pare, Duver-
ney and Hunter envelope the base of the jaw, as well as the
woollen cylinder, which Bottcher thrust within, from the base
of the jaw, in order to form a sort of internal support, whilst
the fragments were sustained by means of a pasteboard ban-
dage applied upon the external face of the bone. Boyer em-
ployed two gages of hollow cork, upon their two faces, with
gutters destined to receive the dental arch, leaving between
them, in front, a space for the introduction of drinks, with the
end of a spoon, and for the flowing of the saliva.
In England a splint of pasteboard is employed, the descrip-
tion of which is given by Samuel Cooper :* "As soon as the
fracture is reduced, the surgeon should adapt upon the base and
length of the lateral parts of the inferior jaw of the patient, a
thick pasteboard, previously softened and moistened with vine-
gar; we should apply, below, a bandage of four divisions, of
which the centre should be placed upon the chin, the two pos-
terior ones fixed upon the anterior part of his cap, and the two
anterior ones fixed to the same, but farther back. When the
pasteboard is dry, it forms the most commodious apparel that
we can imagine for surrounding and sustaining the fracture.
We then apply a plaster of soap upon the skin, to prevent the
inconvenience which might result from the pressure exerted by
the pasteboard, and its hardness."
The different methods, as we see, act only by drawing the
two jaws together ; but many practitioners have thought that it
might be advantageous to render the apparel of the inferior jaw
independent of the support of the superior. In order to accom-
plish this, Dr. Joussetf has constructed, 1st. A splint of tin sub-
mentonniere, which entirely embraces the fragments, and is
fixed to the neck; 2d. A gutter of the same metal, which is
adapted to the crowns of the inferior teeth, and embraces its
fragments ; 3d. A stemof tin, which is soldered to the two pre-
* Dictionary of Surgery, vol. 1, p. 184.
t Medical Gazette, year 1833, p. 222.
376 OPERATIVE MEDICINE AND PROSTHESIS,
ceding pieces, and passes before the jaw. This third piece is
sonietimes only soldered on one side, and fixed to the other by
a screw. By this arrangement, the fragments are enclosed as
in a box, and the patient can at pleasure move the jaws, speak
and eat, without deranging the fragments.
Dr. Baudens, now head surgeon in the military hospital of
the Val-de-Grace, has thought that the end proposed by the
last practitioner quoted, might be better arrived at, by maintain-
ing the fragments reunited, by means of a band passing from
the interior to the exterior of the mouth, and drawing the base
of the jaw within from the skin, in order to tie it upon the den-
tal arch. This method would only be suitable for oblique
fractures of the bone ; but in every case it would be so painful
and frightful for the patient, who, notwithstanding the success
obtained upon a soldier, who fractured his jaw by falling from a
horse, and who presented himself to the Royal Academy of
Medicine, was there about two years before he had courage to
apply to the surgeons without the hospital. We think that the
apparel of Boyer or of Samuel Cooper are preferable to that of
Jousset, which might be very painful.
Although our researches have not conducted us to the discov-
ery of a single instance of complete fracture of the inferior jaw,
such as we have described, in consequence of the extraction of
teeth, we do no less advise young practitioners to proceed with
much prudence, upon subjects affected with scrofulous and sy-
philitic diseases. In these two affections, as we know, the
bone acquires, sometimes, such a fragility, that the slightest
violence would break the inferior maxillary. We met with,
some years since, a person bearing evident traces of the first of
these two affections, so much so, that we feared this accident in
extracting one of the first large molars, which she had requested
us to do. We proceeded with the greatest care, and the tooth
experienced scarcely any lateral movement ; we succeeded well,
but, two or three months after, we learned that this person had,
in consequence of a slight fall, fractured the jaw, at the union
of the anterior third of its body with the two posterior thirds.
OR MECHANICAL DENTISTRY. 377
Luxation of the Inferior Jaw.
This injury evidently belongs as complete fracture, in the
department of general surgery, since it has nothing in com*
mon, neither with the teeth, nor with the osseus border
upon which they are implanted ; but as it may be the result of
an operation belonging essentially to our specialty, which might
cause an extraordinary opening of the mouth, we judge it in-
dispensable to treat of it here, in order that the dentist, may
not be obliged to have recourse to the knowledge of a profes-
sional brother in order to repair an injury which he had himself
occasioned, as it has happened to Fox, who did not fear to
acknowledge it, and as it might many times have happened in
the course of our career, if we had not been always ready to
face it.
1st. To give an exact account of this luxation, it seems to us it
will not be sufficient to know, as elementary authors very briefly
say, that the inferior jaw forms, in the act of mastication, by turns,
a lever of the third or fourth kind, as the next to that body
to be broken finds itself placed upon the anterior teeth or within
the depths of the mouth, that is to say ; before or behind the
masseter muscle— the principle power in virtue of which
this act is performed; it will be particularly necessary to un-
derstand perfectly what takes place in the falling of the jaw.
We see then, that the muscles, by which this last act is effected,
although they serve principally to conquer the resistance of the
elevators, tends in the mean time, always, to curve the angular
form of the lever, and carry the condyle or articulating extremity
of bone, which, pressing violently upon the anterior face of its
capsule, rends it, and glides in front of the glenoid cavity.
There is no lever then of the second kind, whose resistance,
represented by the masseter, was placed between the depressions
and the articulation, but a transformation of this lever into one
of the first kind, in which the inferior extremity of the elonga-
ted masseter becomes the centre of movement, that is to say, the
point around which the jaw tends to pivot, and the head of the
bone the resistance which, vanquished, rapidly carries itself for-
ward. The departure of the head of this from the cavity, the
48
378 OPERATIVE MEDICINE AND PROSTHESIS,
fibres of the masseter, becoming parallel to the body of the bone
in which they are inserted, are necessarily more needed for
maintaining them before than for carrying them back behind.
This luxation, as we have already said, is very difficult, not to
say completely impossible, in early infancy, because the branch-
es of the jaw, at this age, are nearly parallel to the body of the
bone, from whence results its downward movements, passing
around an axletree which traverses the condyles themselves ; it
is also necessary that this falling should draw the bone in a ver-
tical direction, that its articular extremities may depart from the
cavity. The only example of which we have heard of this kind,
is related by Sir Astley Cooper : "I have seen" says he, "a case
in which two children disputing for an apple, one of them
forced it into his mouth and luxated the jaw."
At the moment when the luxation of the jaw is affected, a
sharp pain is felt in the luxated articulations. The jaw remains
immovably depressed and it is impossible to make it meet the
superior ; articulation is impossible or very much embarrassed ;
the projection formed in this natural state behind and below the
ear, is replaced by a depression sensible to the touch. Finally,
the movements of the muscles of the jaw, produce a marked
flattening in that part of the face and in the region of the tem-
ple.
2. An absolute ignorance or a false appreciation of the me-
chanism by which this accident is caused, has a long time led
to the adoption of defective means for remedying it. Success
has been promptly and easily attained only when one has ceased
to carry upon the chin the principal effort necessary to its re-
duction, and when we have perceived that the first indication
to be fulfilled, was to conquer the resistances offered by the
elongated muscles, and to depress the condyles, in order to lib-
erate them, then to carry them backwards to the cavities which
they had abandoned.
This triple indication which, for the good of man, seems to
be a conquest of modern surgery, had, however, been established
by Fabrice d'Aquapendente, as would seem from these quota-
tions : "It is necessary," said this author, "to make the move-
ment contrary to that which it made when it left its cavity."
OR MECHANICAL DENTISTRY 379
The jaw leaves it behind ; it is drawn down, it is necessary there-
fore to elevate the jaw. 3. The muscles drawn from above the
sharp apophysis ; it is necessary then to bring it back. If it
is luxated only from one of its articular cavities, it is necessary
to proceed by a strong movement : if both cavities have been left
the first thing the surgeon should do, is to pull it forward, then
depress it, then push it backwards and lastly upwards."
These various indications are sometimes filled by wedges of
wood and sometimes by levers placed'between the molar teeth, and
upon which pressure is made whilst another person draws from
below upward with a bandage under the chin. This is the
procedure advised by Fox, and a French dentist Dubois Che-
mant, of whom we shall have occasion to speak in our dental
prosthesis.
But the following method which is now adopted as a princi-
ple of modern surgery, is altogether more rational and simple : it
consists in applying and securely maintaining the head of the
patient upon the breast of an assistant, and to place the two
thumbs, wrapped with linen, as far back between the teeth as
possible, and to embrace the whole body of the maxillary bone
with the other fingers bent under the chin ; then to press firm-
ly upon the inferior dental arch with the thumbs, in such a
manner as immediately to completely depress the whole of the
bone; and when we begin to move the condyles, we at the
same time push them backwards, whilst with the fingers placed
under the chin we relieve this part. The contraction of the
muscles of the luxated bone brings the heads of it in place, but
sometimes so quickly that the fingers of the operator might be
bitten if he did not turn his thumbs, or if he had not had the
presence of mind, to place between the jaws in front of his
thumbs a stopper of cork or some other substance capable of
annulling the efforts of the shock.
In a case of this luxation in an unruly gesture, Sir Astley
Cooper, has taken the following course : He says, "I placed
him upon a table in a dorsal decubitus, with a supporter upon
a cushion ; he was held in this position by several persons,
then placing myself behind his head, I introduced between the
molar teeth on each side the handle of a table fork, using the
380 OPRRATIVR MRDICINE AND PROSTHESIS,
precaution to wrap tlie teeth in a handkerchief, and while it was
held in this position, I firmly drew the lower jaw towards the
upper ; the reduction was made with ease and promptly."*
Therefore, then, that which we have said of the jaw, consid-
ered as a lever of the first kind at the moment of luxation, is
found confirmed in all points, by the means employed for reduc-
ing this luxation. It is always a lever of the first kind, which
we endeavor to make a see-saw of The power is in the palm of
the hand of the operator, the thumb which presses forcibly upon
the middle of the body of the jaw is the fulcrum ; the resistance
the condyle which we attempt to carry forward. The masseter
muscle also oflfers a resistance to be overcome, but, it is only
secondary, and it is necessary to use precaution, to prevent the
fingers from being bitten at the moment when this muscle be-
comes the power, and this is only at the instance where the
condyles gUde into their cavities. f
CHAPTER II.
PROSTHESIS OR MECHANICAL DENTISTRY.
The part of out profession, which, under the name of prosthe-
sis, consists in substituting false teeth for those which have
been accidentally lost, or whose sacrifice has been judged ne-
cessary, in remedying certain loss of substance either of alveo-
lar border, or of the palatine vault, constitutes neither a new art,
nor one extensively cultivated by people advanced in civilization.
If, in effect, on the one hand, we find in the writings of Latin
or Greek authors, historians or poets, proofs which evidently at-
test that the civilized people of antiquity not only knew the care
the teeth required for their preservation, but, still more, they
knew how to supply their loss by mechanical procedures, we
• Work quoted, page 126.— Let us remark that the handles of forks which
the people of England use, are not like ours, metallic and flattened, but of
wood, or bone, and as thick as those of our table knives.
t Excellent advise is given upon this luxation in the inaugural thesis, of
Capuroo, given in the year 9.
OR MECHANICAL DENTISTRY. 381
perceive, also, on the other hand, from the accounts of travellers,
that this art is wholly unknown to the people who inhabit certain
parts of the ancient or new world.
We have in favor of the first of these two assertions, the amend-
ment to the eleventh article of the law of the XII Tables, borrow-
ed by the decemvirs of Rome from the Grecian legislature, and
which permitted the bodies to be burned with the gold attached to
their teeth : amendment which certainly applies to artificial teeth,
whose removal was regarded as profanation, and not only, as
Duval seems to believe, to the loose or fractured teeth, that he
had had an idea of adjusting with bands.* In favor of the
second assertion, we find in Bontius,t that the inhabitants of the
island of Java and of some other countries of India, who lose
their teeth at youth replace them by others of gold. Genelli
Carreri says the same.|
But, whatever may be the origin of dental prosthesis, the
sole spirit of civilization, or the result of necessity, we have rea-
son to believe that it never had arrived to a degree of perfection
until the present day, and we can say, without fear of contra-
diction that France^wxih. just reason, prides herself in being the
country in which the greatest progress has been made with its
advantages, and the most capable of extending its use. The
moment is not far distant, doubtless, when each one of us, better
enlightened upon the causes of diseases of the teeth, that is to
say, being convinced that these diseases may result from other
causes than negligence or the progress of age, and led, besides,
by the integrity of the dentists, of our day, which renders their
services accessible to all, will be able with care and with as
little mystery as any other imperfection can, to repair the losses
that these diseases so frequently cause.
* See upon this subject the different commentaries upon the law of the XII
Tables, by F. Holtman, page 55 ; and Bouchard, page 558, etc See also.
Martial, book v. epi. gram, 43, which contains these two verses :
Thais habet nigris, niveos Lecarria devtes :
Q,uee ratio est? eraptos hae habet, ilia suos.
' Thais has black teeth, Lecarria has them as white as snow.
What is the reason of this? the one has her teeth, the other bought them.
Edit, of Latin Classics ofJVisard,
t De Medicine Idderum.
J Voyage around the world, vol. v, page 128.
382
OPERATIVE MEDICINE AND PROSTHESIS,
"There is, however, one thing which should astonish persons
who are struck with the importance of dental prosthesis and
who in acknowledging the tendency that all classes of society-
have to profit by the advantages that it offers, are ready to admire
the perfection that it has acquired in our day ; that is the small
number of works to which it has given birth. What has been
published in effect upon this subject, since Fauchard, occupy-
ing a just place, for prosthesis as for pathology, in the first rank
amongst those who in our profession had had the laudible am-
bition to trace the rules to establish principles, and, consequently
to furnish models ? Two or three works only have merited se-
rious attention, that of Delabarre,* production which proves a
perfect knowledge of the subject, a great habit of judging, and
extreme skill in doing, but who, unfortunately, was possessed of
a mind scarcely methodical enough to be always well under-
stood, and whose desire of being odd, often led him from the
precision of facts, and often beyond possible things. This work
also lost its value, by its want of order and the absence of
general principles, plainly expressed ideas, and by its being filled
with a multiplicity of details which were only useful to those
who already were informed.
From wherever comes this scarcity of works, but particularly
of elementary ones, upon a subject which is daily becoming
more appreciated, for the importance of the laws of hygiene, is
constantly experienced, and while so many proofs, particularly
in large cities, convince us that their practical observance is so
superior?! from this fact, most dentists in making the mechani-
cal part of our art, the principal object of the profession, that
which furnishes the most proof of their skill, and firom which
* Work quoted. — M. J. Audibran has also published in 1821, a Treatise
upon Incorruptible Artificial Teeth; but treating only of mineral teeth, he
has directed all that which he has said of it in the generalities, which makes
it to be regretted that he has not reduced it to few pages.
t The English dentists have long since given us justice in this respect, for
we find in a work published at London, in 1823, by Gerbaux, under the
title of : A Practical Tfcatise upon the most frequent Diseases of the Mouth
and Teeth, and especially the accidents of the Jirst dentition , this ■ phrase :
It is in Paris principally (hat the best works upon this interesting subject have
been published.
OR MECHANICAL DENTISTRY. 383
they desire the most clear advantage, they receive by trans-
mitting publicly the fruit of their experience to their profes-
sional brethren ; in this respect, they will be supposed more
adroit than wise, by passing, in a word, rather for artists than
physicians.
It is not rare even at the present day to meet with dentists,
besides being very honorable and of high standing, (sociably
speaking,) having a contempt for mechanical dentistry ; so much so
as to regard the extraction and the plugging of teeth as the only
operations that they can practice without derogating themselves,
and having the good nature to believe themselves more useful
to society by discoursing upon the incisors of the castor or the
canines of the elephant, then by giving to the disgarnished
human jaw the means of performing all the functions that
nature had primitively given to it. Strange pretension, which
has engendered these views ; happily so few a number, of mixed
practitioners who, under the name of //tedico-dentists, are not
appreciated by the 7nedico-surgeo)i, properly speaking, but by their
true worth, and are with difficulty understood by the public,
whose good sense often leads them to believe that the man of the
art who embraces a speciality ought at least exercise it entirely.
Our advice, is then, that, since dental prosthesis acquires every
day a greater importance, since it furnishes at least half of the
cases upon which we are consulted, it should be studied and
practiced with the same care as the other parts of our profession.
This question naturally presents itself here : should the sur-
geon dentists, as Laforgue wishes, always manufacture all the
pieces of artificial denture; or should he conform to Gariot's ad-
vice, be contented with taking the impression of his pieces and
trust the fabrication of them to his workmen ?
If it were necessary to reply to this question in a single word,
and to adopt one of these two opinions to the detriment of the
other, we would not hesitate to pronounce formally in favor of
Laforgue's, for a very long experience has demonstrated to us that
those who depend exclusively upon their workmen to construct
their artificial pieces, are always obliged to retouch the work, be-
cause whatever care we may take in procuring a model of the
place of a natural tooth, whatever precaution we use to secure
384 OPERATIVE MEDICINE AND PROSTHESIS,
a correct form to the piece, and that style of art, which we call
the expression of the physiognomy, if we may be permitted so to
speak, which the artificial piece destined to occupy the place of
the natural tooth should take, it is impossible to convey to
another, and especially the true disposition of the mouth.
Those who do this work, know very well the difficulty in giv-
ing the numerous details necessary for a simple piece, much
more so, for a complicated piece, how then can a workman,
however adroit and deserving he may be, form a just idea of
that which he undertakes without having an opportunity of
judging for himself the particular character which each piece
should have, a character which the eye can more correctly com-
prehend, than can be obtained from any description?
However just may be this opinion as a whole, it is not neces-
sary however to deduce from it consequences which should
make it too rigorously the duty of the dentist, to do all, and all
alone, of those multitude of objects which pertain to dental
prosthesis. For who wishes in effect to give an exact account
of the fabrication and the slowness of adjustment of some one
of their objects ? it is evident that, although varied but httle as
is the labor of the dentist, he could not accomplish all of this
labor alone ; he would be obliged to be interrupted to attend to
other duties not less inperious.
It is necessary, then, in order to avoid all exaggeration, which
at a later period would be perceived by the student, after he had
become a practitioner, as untrue, to admit in principle that it
does not suffice for the man who wishes to exercise in a proper
manner his profession and to avoid the many shoals in the
practice of prosthesis, to know how to take impressions and to
make moulds, to know the physical laws which govern the at-
tachment of pieces, to know how to mould, to saw, to file, to
bore, solder metals, to precipitate, and to know all the material
and all the manners of work of which they are susceptible, but
it is necessary still more that he should, in the course of his
studies, fabricate himself and all alone all the artificial pieces.
Certain then of being able to direct, because he knows how to
do it himself, a mechanical workman might be made useful to
him. These workmen are ordinarily jewellers, more accustom-
OR MECHANICAL DENTISTRY. 385
ed than any body else to handling delicate and precious objects.
He could direct them to prepare pieces, to solder them in the
right place, and to fabricate all the parts which form it, he could
stop the procedure of the work at any time upon the model, to try
it upon the patient, and in order to make a proper assistant take the
most advantageous part from the workmen he employs, for the pur-
pose of economising time, material and the adjustment of pieces ;
the dentist who cannot fabricate, himself, should always have a
workman at hand ; finally, he should be able to survey the work,
and communicate promptly all his intentions, and instruct him
in all the details necessary for each piece.
"I think," says, with reason, a modern author, "that a dentist
should be in his cabinet, during the construction of artifiicial
pieces, as a statuary in his shop, who conceives and designs his
subjects, by tracing all the divisions upon the marble and trust-
ing only the purely mechanical part to the workmen whom he has
constantly under his eye and whose hands he can direct, so to
speak, so that he can, in the last place, give all the grace and
finish to it, in order to render it a true object of art. It is this ab-
solute necessity of knowledge in medicine and mechanics which
has made at all times and will always make of our profession a
specialty perfectly distinct from all the other healing branches.
But, for a pitiful compensation, there are those who unfortunate-
ly facilitate the access to it, to a crowd of ignorant folks who
believe they have overcome every obstacle when they have
mounted some teeth upon plates or roots, destined to receive
them."
We regret that this necessity of equal knowledge in mechanics
and medicine should not be also admitted by English dentists,
as it is with us, and most French practitioners, as the following
phrase, extracted from an English author whom we have quo-
ted, proves : "I admit that the prodigious extent of knowledge
that the art of the dentist demands can rarely be in the posses-
sion of one individual. I think that it would be advantageous
to its progress if the mechanical part was executed only by ar-
tists who make it their profession." In abandoning such an
opinion, they may expect, without doubt, that superiority which
we meet with in many of them.
49
386 OPERATIVE MEDICINE AND PROSTHESIS,
B^rom these general considerations, which show the opinion
that we entertain and what utihty we would naturally make of
dental prosthesis, and the manner its study should be consider-
ed by the dentist, let us pass to the methods of execution, by
confining ourselves to general views, that is to say, by omitting
all minute details of fabrication which belong more to the jew-
eller's art than to the dentist's, and which, we have already said,
are of no use to the student who does not frequent the work
shop, since he could not comprehend them, and would be com-
pletely useless, superfluous even for those who have practised,
since it would only be a repetition of that which they already
know.
Of substances employed for the construction of Pieces of Artifi-
cial Teeth.
Different in this respect from most authors who have written
upon our art, and who give the name of joieces to the re-union
of many artificial teeth, we employ this word only to designate
every object which belongs to the replacement of any portion
whatsoever of a denture. If it is only composed of one tooth we
call it a simple piece, if it is of many, we call it a complicated
piece ; if it is, in fine, of as many teeth as the jaws naturally
have, it is then a complete piece, if we like a denture or a ratclier.
It has been, doubtless, in the construction of these pieces as
in all objects which are classed by their nature among the arts :
before seeking the necessary and agreeable, we have necessarily
been occupied with the simple and the useful. As the first
substance susceptible of being cut in the form of coin was suf-
ficiently hard to resist the pressure of the aliments in mastica-
tion, and was white enough to approach the color of the teeth,
that was first used to replace them.
But in proportion as civilization, by its progress, caused luxury
to be desired, we became necessarily more exacting; we not
only contended for that which was useful, but we desired to
add to solidity of force, beauty, and all the other advantages in-
herent to the natural teeth themselves. With this design we
then successively used the bone and teeth of the calf, those of
OR MECHANICAL DENTISTRY. 387
the horse, the teeth of the sheep, of the stag, and many other
animals, the ivory or tusks of the elephant, the teeth of the hip-
popotamus, of the whale, of the morse, human teeth, and finally
teeth made of mineral paste.
Of these diiferent substances, the only ones which are gene-
rally employed at the present day, are the teeth of the hippopota-
mus or sea-horsey human teeth and those of mineral paste ; these
are consequently, the only ones of which we shall treat.
Ivory, which has been employed a long time, and whose an-
tiquity is incontestable, as Martial,* who we have already quot-
ed, speaks of it in formal terms, is nearly completely abandoned,
for two reasons : first, whatever may be the age of the animal
which furnishes it, it is not of a texture sufficiently resisting for
the action of the saliva and the buccal mucus, but decomposes
and soon is destroyed. This slow decomposition necessarily
gives the breath an unpleasant odor ; which is particularly the
case with the teeth of the wor^e, vulgarly called the sea-cow, or
those of the whale, which we find sometimes mingled with
those of the sea-horse, and which is not much used, excepting
for bases, for want of harder substances. The second reason
which causes us to reject the ivory is, that it is ordinarily marked
with small whitish spots which give to it a greenish color not
suitable for imitating the texture of the teeth.
The bone of the beef, of the horse, and of the stag, ichich are
deprived of enamel, and very porous, imitate but very imperfectly
the natural teeth, and soon turn yellow, however cleaned and
whitened they may be kept. But, the extreme hardness
of some of their parts, their low price, and above all the difficul-
ty experienced, under some circumstances, in procuring others,
has induced some dentists to employ them as bases. Finally,
the teeth of these same animals, properly cut, have sometimes
been employed ; but then it is important that they should be
procured from old animals, because their tissue is more resisting
and their canals entirely or in a great measure effaced.
* Sic dentata sibi videtur ^gle
Ernptis ossibus, indicoque cernu.
388 OPERATIVE MEDICINE AND PROSTHESIS,
Teeth of the Hippopotamus.
The hippopotamus or sea-horse* placed by Buffon in the class
of mammiferous animals, in the order of pachydermata,t is, as
we know, a shapeless and monstrous animal which is between
the sizes of the elephant and rhinoceros. They inhabit the
banks of large rivers, particularly those of Africa, as the Nile, the
Senegal or Niger, the Gambria, the Zaire, in the midst of
which they pass a part of their lives. They are no where so com-
mon as at Cape Mesurado.X The most remarkable thing about
these animals is, that their teeth are serrated more than those of
the elephant, and the whiteness of which is preserved for a much
longer time without changing, a quality which ivory does not
possess it, changes quickly when old ; they are, therefore, more
frequently used in dental prosthesis. Their employment is
much more ancient than is generally believed, Faiichard ex-
presses himself thus with regard to them : "The human teeth
and those of the sea-horse are preferable to every other material,
because they have their enamel and more strongly resist the ac-
tion of bodies which come in contact with them."
Lefoulon then commits an error in saying, *Hhal he had had,
for a long time, an idea of substituting them for ivory. ^^ Let this
be as it may, of the /or^?/-/oMr teeth with which the jaws of this
animal are furnished, we use only the canines, which are the
tusks, and the incisors.
The canines are necessarily the largest and longest, especially
in the inferior jaw. They generally weigh two or three pounds ;
but we have known some of them to weigh six or eight. Bent
* Delabarre thinks we have done wrong in giving the name of sea-horse
to the hippopotamus. All naturalists call the animal under one or the other
of these two names. The etymology of the two words proves the resemb-
lance which we believe, exists between the one and the other. The inhabi-
tants of that part of Egypt where it is found, named it the foras elbar, which
signifies a sea-horse.
tSee Complete Works, vol. 4. (edit, of 1837.)
I Voyage nf JJesmaru, vo\. 2, page 148. See also Kolbe, description of
the Cape of Good Hope, vol. iii, chap. 3, and Adison's voyage to Senegal,
Paris, 1757, page 75 ; &c. &c.
OR MECHANICAL DENTISTRY. 389
as the tusks of our wild boar, they have one of their faces flat,
and the other convex. Shghtly facing in regard to their length
towards their plane part, they are only enamelled upon their ex-
ternal or convex side, which fact prevents us from employing
them for the same purposes as the incisors ; but their superiori-
ty in size renders them fit, even when broken in pieces, to be
employed for the construction either of complete dentures, or for
bases upon which we may fasten enamelled pieces, whether
human or mineral teeth. These are those which we commonly
call the teeth of the sea-horse. As, in many circumstances, the
enamel with which they are furnished may injure the work for
which we wish to submit them, we can deprive them of it either
by breaking it in scales with the scissors and hammer, or by
using the grindstone, or even by acids. When we employ this
last method we should be careful to prevent the acid from corrod-
ing the parts not enamelled ; in order to prevent this, we should
place upon these parts either tallow or soft wax.
The incisors are short, half cylindrical in front, hut deeply
indented behind. The upper ones are covered with a very
thick enamel, which closely resembles that which covers the
human teeth ; the curve which they describe before permits
them to be cut in four, six and sometimes even in eight perfectly
enamelled teeth, whose disposition corresponds exactly to the
form of the alveolar arches. Those in the lower jaw are less
sought, because they are without enamel : they are improperly
called the teeth of the sea-cow. They are rounded and some-
times are of sufficient size to be used for dentures in a single
piece ; they are often confounded with those of the morse, which is
the true sea-cow, another great amphibious animal, which, by its
habits, and especially by its conformation, approaches infinitely
nearer to the whale kind than to quadrupeds.
As we often find in commerce the teeth of the morse and even
of the whale mixed with those of the hippopotamus, we should
recollect that the first differ essentially from the second, first,
because they are less rounded and nearly straight, instead of
being curved and half cylindrical as the canines or tusks of the
hippopotamus, or hollow behind as its incisors ; secondly,
because they are simply covered with a kind of yellow and white
390 OPERATIVE MEDICINE AND PROSTHESIS,
shell instead of being provided with enamel : besides they have
not as much hardness as ivory ; the saliva then quickly ef-
fects them.
The canine or incisor teeth of the hippopotamus are far from
presenting the same appearance, and from being of the same
quaUty. We find in trade some large, middling, small, old, white,
brown, gray, even marbled, half round, flat and sided ones ; but
all of them, when we cut them cross-ways, present a furrow more
or less marked, which, under the form of a curved hne, cuts their
great diameter. As this line is formed of material more tender
than the rest of the tooth, and consequently as it is more quickly
changed by the fluids of the mouth, it should be entirely remov-
ed when a denture is to be made from it, this can always be
done when the tooth is of sufficient size.
In general, the teeth of the hippopotamus, from which we
intend to form enamelled pieces, should be white exteriorly,
without deep furrows or clefts. Those which are brown have
no enamel, but can, nevertheless, be used. But whatever may
be the beauty of the substance, and whatever piece we may
choose, its excessive whiteness renders it unsuitable for use,
without previous preparation, particularly when it is first used ;
it, unfortunately, soon loses this brilliancy, only to take a yel-
lowish or bluish tint, which never leaves it. Thus, dentists
who wish to put up very neat pieces, use it only for bases or
supports, upon which they attach natural or mineral teeth.
When it is used only for this purpose, the fibres should not
have a vertical but a horizontal direction, because it will secure
to it a much greater power of resistance.
As it regards the method of giving to the hippopotamus or
any other substance of similar texture, the form of the teeth and
gums, it constitutes an art similar to that of the manufacturing of
chessmen and dice, and to that of sculpturing. It is not suffi-
cient, at the present day, as in the times of Fauchard, in order
to imitate teeth, to establish separations on the anterior part of a
piece of hippopotamus, nor either to reduce the extremity of
each piece to a point, or by filing it cross ways, according as we
wish to represent an incisor, canine or molar ; but it is necessary
that the piece should represent, as nearly as possible, the teeth
OR MECHANICAL DENTISTRY. 391
whose place it is to occupy, so that it will not be detected as
artficial.
It is necessary that we should divide the hippopotamus in
pieces of convenient size with a saw. The piece to be used
once selected, the dimensions of the piece should be described
with a compass, and the details traced with a crayon, and the
form imprinted with a rasp or file ; but the engraver, scraper and
burin, employed in the same manner as in engraving and sculp-
turing, can only aid us sometimes, however, by the grindstone
and drill moved in a lathe, serve to complete the work, and give
it a convenient finish. We next polish it, colored or not, with
a small quantity of very finely powdered stone, on a piece of
soft wood or linen, or by some other means. Without wishing
to describe in detail the different methods of working hippopo-
tamus, methods which must necessarily vary according to the
piece we wish to construct ; we will, however, examine each
fundamental preparation through which it must pass before it is
ready to be placed in the mouth. *
We have said that we divide the hippopotamus into convenient
pieces with the saw ; but this instrument will have to be as
well serrated and tempered as if it had to be used on a piece of
iron or brass, because the enamel of this substance is so hard
that saws of ordinary tempering would soon be dulled, bent or
worn out, without advancing into the substance of the tooth. It
would also be prudent to cut through the enamel, with a trian-
gular file, before using the saw. In order to do this, the tooth
of the hippopotamus should be placed in a vice, enveloped,
however, in a piece of cloth or skin, so that the tooth, being
firmly seized, will not slip through the jaws of the instrument,
at the same time, so that the enamel should not be cut except-
ing in the points seized ; we then make a groove with the file,
around the tooth, upon the parts where we wish the saw to act.
As the saw cannot proceed very far into the substance of the
hippopatamus, no more than it could in the ivory, without heat-
ing and without softening it by its own caloric, we should stop
occasionally, in order to allow it to cool, at least we should
watch it, in order to prevent it from softening. When the pieces
are so divided, we should preserve them perfect, in order to
392 OPERATIVE MEDICINE AND PROSTHESIS,
make the piece destined to represent the teeth and their base of
the same piece, leaving the enamel for the first, and calcining
it by the flame of the lamp, whilst we use the grindstone for
the latter. But even if we wish to saw them for isolated teeth,
we cut them in as many pieces as we wish to make, always
giving the preference to those which are covered with the most
regular enamel. Iti this latter case, we may avoid the brilliancy
of that enamel upon its edges, by commencing to file it in these
places ; if we desire it, we can effect this by means of a drill.
When the hippopotamus is cut for the purpbse for which we wish
to employ it, the several parts of the piece are then worked in de-
tail. In order to do this, ancient dentists placed it in the same
vice employed for its first division ; but we are daily convinced
it is better to hold it in the hand whilst we are working it and
apply it upon the trennel of the work table. Some dentists
fasten it there by means of a double cord passed through a hole
pierced in the trennel of the table and which is confined to a
treadle upon the ground. When they wish to fix a piece firm-
ly between the trennel and the cord, they fasten it in the handle
which forms this, and move it with the foot placed on the treadle.
Thus maintained, the piece cannot escape the instruments em-
ployed in working it, and it is not liable to be damaged by the
jaws or serres of the vice, if we cover these last with cloth,
skin, or cork; but this method would not be appropriate for
working it in the hand.
When we wish to construct a base, we take a piece not enam-
elled, and whose fibres run horizontally ; we cut with an en-
graver^s tool, or with a lathe drill to the model of which we shall
soon speak. We then form a base which encases the alveolar
border upon which it fits in such a manner as to subserve the
purpose for which it is to be used. We then draw with a pen-
cil, but only in front, a curve similar to the one described by
the gums, then, either with a gouge^ or with a rasp^ or with a
drill, we scollop or curve each arch, commencing with the prim-
itively fixed median line.
If we, on the contrary, wish to make a simple tooth, an in-
cisor for example, the piece of hippopotamus furnished with its
enamel being properly arranged, we hollow it to the part upon
OR MECHANICAL DENTISTRY. 393
which it IS to rest, either upon the osseous or metalhc bone to
which it should be united ; this is accomphshed with the half
round file, or that which we call the rat-tail file, sometimes also
with the engraver. Then, in order to hollow the posterior part,
we saw the piece obliquely from the bone to the summit ; but
when we have passed through about two-thirds of its thickness,
we stop to give a vertical stroke to the saw which shall meet the
first incision ; but this would be better accomplished with a half
round file. We should next commence with the various details
of its form.
We will observe in this respect that if we wish absolutely to
make, from the hippopotamus, teeth furnished with enamel upon
their anterior and lateral faces, we may accomplish it by cutting
the hippopotamus upon certain of its projections which appear
on it. This method of procedure occasions a great loss of the
material. It may, however, satisfy those who refuse, for reasons
either good or bad, to make use of human or mineral teeth.
We have made many complete pieces and even complete sets of
teeth in this manner.
Finally, to manufacture a complete denture with the teeth
and their base, sculptured from a single piece is decidedly the
most difficult piece of dental mechanism that can be made from
the hippopotamus, for it not only possesses difficulties inherent
to the teeth and to their basis, but still more, these which are the
result of the union of the two parts. In order that a piece of
this nature may be well made, the dentist should trace from the
mouth of the person for whom it is destined the medium verti-
cal line which should serve him for regulating the division of
the teeth. He should then draw these last with the crayon,
taking care to leave for each of them the proper size.
Thus the central or great incisors should be broad and flat, par-
ticularly those of the upper jaw, which are about a quarter larg-
er than those of the lower jaw ; the lateral or smaller incisors,
should be a third narrower ; the canines more or less rounded,
elongated or pointed, according to the person, should be nearly
as wide as the lateral incisors. The small molars should be a
fifth smaller than the canines, and the large ones should have a
volume equal to the two small ones. In order to hollow the
50
394 OPERATIVE MEDICINE AND PROSTHESIS,
triturating face of the large and small molars, some dentists em-
ploy a sharp drill ; we prefer the engraver, which cuts less cir-
cularly.
We employ the same means for perfecting the hippopotamus,
that we do for all the other materials which we use in dental
prosthesis. The instruments used are the drill, a small lathe
and wheel, with drills of various sizes, drill stock and bow.
The end of the drill stock is placed in one of the cavities which
are always found on one side of the jaws of the vice of the lathe,
or upon the side of the trennel, the other extremity is placed
upon the object to be pierced.
The orifices made in the hippopotamus, like any other animal
substance employed in the construction of pieces of artificial
denture, should always be rather smaller than larger than the
points which they receive, because it would not be well adjust-
ed if we were not to use some force, in order to introduce them
there. The perforation of these orifices also demands certain
precautions. Thus, it is necessary that the gimblets which are
employed should be well grooved ; otherwise the cut particle
will not escape or be taken up by the gimblet which will
become heated, lose its temper, bend and break. This incon-
venience may be prevented by often withdrawing and empty-
ing the hole and dipping it in water. If it breaks in the piece,
and when the part which remains cannot be seized with pincers,
we should perforate the piece directly opposite and drive it out
with a small punch. Finally, when the work is finished, it
should be polished by simple means, such as have been already
indicated, but some dentists do it with walnutor willow wheels,
slightly moistened, upon which they apply a little emery, putty
or protoxide of tin and pulverised pumice-stone ; then the pro-
cess is completed by polishing it with the fingers and dry pow-
dered pumice-stone.
The hippopotamus has particularly this advantage ; the same
pieces can be often retouched. We employ, for example, that
which is ordinarily sufficient for those plaster moulds, we at
first make the piece of wax, then we cover the greater part of this
mould with black or red, diluted in gummy water, we then
place the piece on, and when it is removed it will be marked
OR MKCHANICAL DENTISTRY. 395
with small black or red spots, according to the color employed,
indicating the part which requires to be cut out with an engrav-
er, but always with care, so that all the points which should
touch the subjacent model should be covered with the color
with which the latter is impregnated. As to the method of
tinting the hippopotamus, destined for imitating the gums,
we shall speak of it in treating of the method of arranging the
basis upon which we mount the teeth. Let us content ourselves
by saying here, that in order to give to the isolated teeth a yel-
lowish tint approaching to that of the natural teeth, we boil them
in a decoction of coffee or tea, or of any other substance con-
taining a little tannin.
The dentist who has a large practice in dental prosthesis
should always keep on hand an assortment of the teeth of the
hippopotamus of all sizes, so as to have constantly upon hand
the form of the enamelled part which he may desire. Those who
live in the country and make but few pieces can easily procure
them from the workmen of large cities. We cut these teeth in
circular pieces of a certain thickness, whiten the enamel upon
the grindstone and preserve them for use in a cool place. It is
well to be warned that this substance is sold by weight, that
merchants keep it in cellars or moist places so that it may absorb
humidity and weigh more. It would be well in this case, in
drying it, to be careful to not expose it to the sun, nor to too much
air,because it would cause it to crack, particularly in the seams or
unenamelled parts.
Human Teeth.
Does it not seem, in the first place, that no indication of pros-
thesis could be more easily and more surely fulfilled than that
which is relative to the teeth, since we cannot only replace nature
by nature itself, but we can directly substitute for a human tooth
one exactly similar. Three reasons are urged to prove, that the use
of human teeth has not been as frequent as we might suppose, and
have engaged men of art to seek substitutes, which might have
their advantages without their inconveniences.
First, their use has been necessarily interdicted, or nearly
396 OPRRATIVF IMRDTCINK AND PROSTHESIS,
void l)y those people whose religious belief considered it as an
act of sacrilegious profanation to touch or despoil the dead ; then,
again, many persons have a great repugnance to having teeth
which had belonged to others in their mouth ; finally, they have
to be frequently renewed, because they have that in common
with all animal substances which lose their brilliancy and
color, they form a striking contrast with the neighboring teeth,
and are attacked and destroyed by the saliva and other fluids of
the mouth. They also, at certain times exhale a very disagreea-
ble odor.
However strong these reasons are, they have yielded to
the want which many have experienced, who have been de-
prived of their teeth, of hiding this loss ; thus the human
teeth are sought by those who prefer a perfect imitation of their
own. In times of war, very beautiful and healthy ones, corres-
ponding exactly to their own, can be procured ; but in times of
peace, we can seldom obtain them, except in two ways : we
buy them from the infirmaries or hospitals, and from cemete-
ries. As to the hope which Delabarre gives to dentists, of being
able to procure enough by the extiSLCiion of supei'numerary teeth,
we have never known it to be realized ; and we would caution
young practitioners never to depend upon this source for their
procurement ; first, because supernumerary teeth are very rare ;
secondly, because, amongst those which we extract, it is very
rare that we have one whose form is sufficiently perfect to be
useful; the most of them resemble simple osseous tubercles,
which approach more to canines than to any of the others, as
we have already observed.
In regard to teeth taken from cemeteries, they are always
bady because, when they have remained a long time in the
earth, their enamel is frequently changed, and, most ordinarily,
the osseous substance has commenced to decompose, which
renders them yellow and brittle.
The last thing to be noticed, is the manner of choosing the
human teeth, and the processes through which they should be
passed, previously to being used. The best ones are those
which are neither caricd nor cracked, which have been ex-
tracted, a short time after death, from individuals, aged from
OR MECHANICAL DENTISTRY. 397
twenty to forty years, a period of life when they are best capa-
ble of resisting the various forces to which they are necessarily
subjected. When they are taken from younger subjects, they
are less resisting, and have too large a central cavity; upon sub-
jects more advanced in age, they are already yellow and worn.
It is necessary to select such as are entirely healthy, and to re-
ject all which, although untouched, and have a reddish or
blackish appearance interiorly, because this color is the result
of a pathological state, and which, like decayed teeth, are soon
destroyed by contact with the saliva. With regard to what
some authors say concerning the filling of those places which
are slightly decayed, with hippopotamus, it should not be done
by any dentist who attempts to make a perfect operation.
In the purchase of human teeth, we should place more value
upon the six anterior teeth of the superior jaw, particularly to
the incisors, which we have occasion more frequently to use ;
we must not, however, neglect to procure those of the inferior
jaw, which we use as frequently as any other.
When they are selected, they should be freed from tartar,
and the periosteum and portions of the alveoli, with a scraper.
Some dentists then perforate their roots, and string them on a
thread; then, before fitting to the mouth, they soak them eight
days in simple water, renewed every twenty-four hours ; then
clean them again, with a piece of tender wood, slightly softened,
and covered with a little pulverized pumice stone; then they
rub them with silk, and, finally, they terminate the cleaning by
washing them, and leaving them several days in soap and
water. Others commence with this last operation, and also
boil them in water. Although this precaution seems to give
more security, as it regards their cleanliness, yet it does not ap-
pear to us to compensate for the tendency which the osseous
part has to become yellow ; we therefore abstain from it.
If some slight spots remain, which cannot be removed by rub-
bing the hand upon them, they should be removed by submitting
them to the action of a wheel of tender wood, mounted upon a
lathe; and if the enamel is slightly attacked, the discoloration
may be removed by placing them upon a grindstone ; we then
polish with a wooden wheel and the dust of dry pumice stone.
398 OPERATIVE MEDICIISTE AND PROSTHESIS,
In no case should the teeth be cleaned with concentrated
acid, because the enamel would be acted upon by it, and doubt-
less sooner than if the teeth were living. It is well to observe,
however, that the care which we should take to select the most
beautiful teeth, should not go so far as to reject all those which
have some defect of color or form, because some of these might
suit exactly to a case which might present itself. It is because
a complete assortment of teeth is not constantly kept on hand,
that trouble is frequently experienced in finding such as have
a perfect resemblance to those which we wish to replace ; incon-
veniences which the manufacturers of mineral teeth have par-
tially overcome.
The teeth selected, cleaned, and arranged in sets or by series
of incisors and canines, &c., it only remains to provide for their
preservation. For doing this, each dentist has a method which
he thinks preferable to every other. Some leave them in sim-
ple water, or alcohol diluted with water ; others cover them with a
layer of white wax, oil and chalk, or keep them in lard ; others,
again, preserve them dry, in drawers filled with bran or flax-
seed. These three processes have each their inconveniences :
First, teeth, on being taken from water, and exposed to the air,
crack ; as regards the second, the teeth become yellow in pro-
portion as the greasy substance in which they are kept acquires
rancidity ; and teeth kept in the manner last described, are liable
to crack.
It is better to 'preserve the incisors and canines by implanting
their roots in wax. This method, which we were the first to
employ, is excellent ; not only for preserving them, but also for
enabling one to select readily the ones which he may desire.
The advantage which it has over the method of keeping them
in bran or flaxseed is, that being arranged in sets by the side
of each other, they may be easily compared with those by the
side of which they are to be placed; and over the method of
preserving them in water, it enables one to distinguish their
true color more readily.
OR MECHANICAL DENTISTRY. 399
Mineral Teeth.
If in supplying an artificial piece, the dentist has but one object
in view, and that to perform the functions of the organ which for-
merly held its place, either for the mastication of aliments or
the articulation of sounds, and of exactly imitating nature in
form and color, the employment of human teeth would, at once,
solve the problem. But by the side of these two questions of
the identity of use and of perfect imitation, we find a third
which they are far from fulfilling by the tendency which they
have, as all animal substances, to progressively deteriorate. It
is that which is relative to their preservation. It is not then
astonishing that we have sought to replace lost teeth by a sub-
stance that joins unalterability to durabihty and color, and it is
evident that we cannot find this substance within the animal
and vegetable kingdoms ; it can only be found in the mineral
kingdom.
History of their discovery. — To whom truly belongs the merit
of the first discovery and manufacture of these teeth ? Some say
to an apothecary of St. Germani, named Duchateau, Avho, in or-
der to remove the inconvenience of an artificial denture constant-
ly undergoing decomposition, and giving forth a disagreeable
odor, fabricated a hard porcelain denture and communicated his
discovery to the Royal Academy of Surgery in 1776. Others,
on the contrary, say, to Dubois-Chemant, surgeon of Paris, who
struck with the disagreeable odor of the breath of a lady, whose
gums were becoming diseased by the contact of the denture of
hippopotamus which she had worn for a long time, and,
which Avas ni a complete state of decomposition, conceived the
idea of manufacturing a porcelain set of artificial teeth, and pre-
sented the result of his labors in 1789, not to the Royal Academy
of Surgery, as Delabarre erroneously supposes, but to the Socie-
ty of Medicine, of which it is said, it was coldly received by its
members.
Not to the prejudice of either of these individuals do we say,
that it was to Fauchard the credit belongs of first suggesting
the substitution of mineral for animal substance for artificial
teeth; to be convinced of this, it will only be necessary to refer
400 OPERATIVE MEDICINE AND PROSTHESIS,
to chapter xix of his work, entitled manner of enamelling the
teeth or artificial dentures, where he thus expresses himself:
"I have thought that advantage might be derived from a regu-
lar and unalterable coloration from enamel artificially composed ;
I have also thought that I might from this not only perfectly
imitate the enamel of the teeth, but the gum, in cases where it is
necessary to replace the teeth in whole or in parts of sets. With a
view to success, 1 have consulted the most able enamellers, and
by the conversations which I have had with them, I have ren-
dered practicable that which 1 believed no one else has ever
thought of. We have imitated the natural eyes with artificial
enamelled eyes ; but we have neglected the application of this
art to pieces of artificial dentures ; however, besides all the ad-
vantages which artificial teeth have over enamelled eyes, they
serve, as these, to ornament and at the same time to repair
deficiencies of parts whose deformities displease or offend the
sight."
It seems to us clearly demonstrated by this passage, that Fau-
chard not only imitated the enamel, but still more the different
shadings of which the natural teeth are composed. "In order
that the enamel may be better prepared," says he, "we should
endeavor to imitate those by the side of which the artificial teeth
are to be placed." "We cannotdoubt, then," says Audibran," with
reason, that Fauchard employed different coloring materials in
his enamels." Certainly, it was not far from this period when the
invention of artificial teeth made entirely of porcelain was made;
that which Fauchard adds, strengthens still more our conjectures.
"The advantages of enamel employed for artificial teeth," said
he, "is not only confined to the ornament which it furnishes, but
from it there is a still greater result, the teeth, or enamelled den-
tures of the sdimQ,will exist a very considerable time, since the en-
amel is a substance scarcely suscejjtible of change or alleralion.^^
We have had for some time in our possession a piece made by
Fauchard himself, and which proves the truth of the observa-
tion of Audibran.
It is impossible, as we see, to demonstrate in the clearest man-
ner the principal advantages of teeth composed entirely or in
part of mineral substances ; it is evident that, the necessity of
OR MECHANICAL DENTISTRY. 401
employing an incorruptible material and nearly unalterable,
being well established, there was nothing to do but to pass
from the enamel to porcelain.* Now, had Fauchard been
inspired by the writings of Guilman, who, before the publica-
tion of his treatise had given, for artificial teeth, the for-
mula of a paste composed of white loax, softened with a little
gui7i elemi, and in which is added a powder of wAf/e masiicy of
coral and of pearl? We do not admit even this supposition, and
every one must at once perceive, without being too much in
favor of Fauchard, that there is an infinitely greater difference
between his enamelled teeth and the composition of Guilman,
than between these teeth and those which are used at the pre-
sent day.
As to the person to whom we must positively attribute the
merit of that which we call more an invention than perfection,
it seems to be well established, though Delabarre has said of
it that it is the apothecary Duchateau, for whom Dubois-Che-
mant had obtained the secret and perfected the work, of which
he had had the precaution to secure a brevet of invention. f
It was, unfortunately, of mineral teeth, as of a great many
other things, the praises of Dubois-Chemant, whom we were
obliged to regard as their inventor, were as hurtful to their
propagation, as the epigrams of those whose interest it was to
oppose them. In short, whilst this practitioner discontinued
proscribing all substances which, until then, had been em-
ployed for the construction of teeth, and attempted to demon-
strate, in an emphatically written pamphlet,| that the employ-
ment of human teeth might cause the most serious diseases,
his opponents, on the other hand, endeavored to establish,
through the Journals, that mineral teeth were dangerous, be-
* We find, also, ia a work entitled Researches and Observations upon all
the parts of the Art of the Dentist, published in 1756, by Bourdet, that
this distinguished practitioner, who flattered himself to have studied and
understood the treatise of Fauchard, has employed rose enamel in order to
form the gums of some pieces of artificial teeth.
f See the Annals of Arts and Manufacturer, vol. 15, p. 141.
f Dissertation upon the Advantages of JYew Teeth, and Denture without
odor. Paris, 1789.
51
402 OPERATIVE MEDICINE AND PROSTHESIS,
cause they dissolved in the mouth and caused a metallic taste
which incommoded and injured the health of those who used
them. Fatigued by this contest, Dubois-Chemant went to
England, where he transported his industry, and took also a
brevet of invention.
About fifteen years after Dubois Foucou, one of those
who most bitterly opposed the use of mineral teeth, re-
nounced his prejudice, and sought to correct the imperfections
of a procedure which appeared to have, from the method
adopted, the advantage of securing greater durability to these
teeth. His first attempts did not wholly succeed, because his
teeth, made of tender porcelain, softened and finally decom-
posed in the mouth, under the influence of the buccal fluids.
He was not, however, discouraged ; he made fal'ther efforts,
and not only arrived at advantageous results, but he had still
more, the credit by the publication of a dissertation, in which
he made it a duty to throw, no mystery in relation to his re-
searches,* of fixing the attention of his professional brethren
on this new procedure, and of exciting their emulation.
Dubois Foucou, like tlie rest of those who were engaged in
the fabrication of mineral teeth, prepared the artificial pieces
in blocks comprising several teeth united together. To M.
Fonzi occurred the happy idea of making single teeth, and at-
taching them to a plate by means of little platina cramps, which
were introduced into the paste before it was burned, remaining
firmly fixed after this process was completed. This innova-
tion called forth a very favorable report from the Athenasum of
Arts, which awarded to M. Fonzi a medal and crown, although
he withheld the knowledge of the preparation of his pieces,
which he designated by the name of terro-metallic teeth, or
caliodontes, (flint teeth.)
Since the time of M. Fonzi, there have been many improve-
ments in the manufacture of mineral teeth, and it may well be
believed, that the greatest degree of perfection possible has
now been reached. We will present the details of their com-
position, which it is indispensable should be known, even to
* Exposition of a New Method for Manufacturing Composition Teeth.
OR MECHANICAL DENTISTRY. 403
those who will find it impossible to devote any attention to
their manufacture.
General Composition. — Mineral teeth, in imitation of human
teeth, are composed of two substances: one is the paste or
body of the tooth, refractory and opaque, which is called the
base ; the other is vitrifiable, slightly transparent, possessing
the clear and life-like hue of the surface of the human teeth;
this is the enamel; and is known in this connection, as the
coverijis^ of the base. The base is nothing more than the porce-
lain earth, called, in commerce, kaolin^ or the argilaceous
earth of Limoges, {argiliform feldspar.) The covering is the
petunse, or flint of Limoges, {granulous feldspar^ which is
used for the enamel of porcelain ; the fusibility and transpa-
rency of this substance, however, it is necessary to modify by
the addition of a little kaolin.
These two substances suffice for the composition of ordinary
porcelain, which is not to be exp§sed to the action of fire; but
as mineral teeth are required, after being burned, to undergo
intense heat, as, for instance, that attendant upon the process
of soldering, an infusible substance is added, such as sand,
gres^ (a sort of brown free stone,) silex or the earth of Vanvres,
already burned, which, by isolating the earthy molecules, fur-
nish the substance with imperceptible pores, through which
the caloric diffuses itself without causing too forcible and sud-
den an expansion. For this reason the base or paste is gener-
ally formed as follows :
Porcelain paste of the manufactories, . . 20 parts.
Sand, grts., or white silex, 1 part.
And the enamel, or covering:
Enamel, of the porcelain manufactories, 5 or 6 parts.
Porcelain clay, 3 parts.*
Coloring. — But if we were to be content to use these sub-
stances only in the manufacture of mineral teeth, we should
have teeth perfectly white, and, of course, unlike the natural
teeth: it is absolutely necessary, then, to find means of giving
* This large proportion of earth gives to tlie mass only a half fusibihiy ;
the oxydes used for coloring, give it all that is required in this respect.
404 OPERATIVE MEDICINE AND PROSTHESIS,
them a permanent color, varied with all the shades of the
natural teeth. This means has been found in the addition of
certain metallic oxydes, of which the various degrees of oxy-
dation produce shades very varied, even such as bear no resem-
blance to their prhnidve colors; for instance: gold, in leaves,
well mixed with the paste, or enamel, gives a violet; hydro-
chlorate of potassium, red; the grey or yellow, hydro-chlorate
of platinum give the first, blue^ the second, black, etc., etc.
Authors, who have written upon the subject, have not been
perfectly agreed in relation to the coloring properties of the va-
rious oxydes; this diversity of opinion has arisen, doubtless,
as much from the different quantities in which they have been
used as from their mutual combination, i. e., the influence
they mutually exercise upon each other; but particularly from
the various degrees of heat to which they are subjected by the
manufacturer.
Dubois Foucon, whose processes were, certainly, very dif-
ferent and very far inferior to those followed at the present
day, was perfectly aware of the coloring power of the metallic
oxydes, for thirty years ago, he said :* "The principal earth
which serves as a base to the different materials which enter
into the compound forming the paste, may be colored by
the addition of metallic substances alone, in the state of
oxydes, or combined with other kinds of earths or sands. I
limit the coloring of the teeth to three principal shades: white-
blue, white-grey, and white-yellow." For the first shade he
made use of terre de renard, and terre d* ombre, calcined, to
which he also added a small quantity oi cobalt, when he wished
to obtain a deeper blue; for the second shade he employed the
terre de Dourdan et d''ombre; for the third, which he found
more difficult to obtain, he proposed the use of frities or cal-
cines.'f the first composed of manganese, sand of Belville, and
petunse, the second of petunse and terre d'ombre, to which he
added the last named material to produce a deeper yellow.
* Ouvrage cite.
t la the language of the manufactory, is thus termed each burning of
the substances used for coloring, either the base or covering used in the
manufacture of mineral teeth, or the enamel for the gums.
OR MECHANICAL DENTISTRY. 405
M. Delabarre used cobalt to produce a blue color; platinwn
for black-white ; gold for violet and red ; bismuth for blue-grey ;
mercury for grey; silver for white-yellow; iron for red-yel-
low; manganese ioi Q^xey ; uranium and ^i^a?fiMm for yellow-
straw ; and, finally, antimony for pure yellow.
M. Audibran used no other materials for this purpose, than
the oxydes oi titanium^ zinc, uranium and gold, to which he
added the hydro-chlorate-ammoniac of platinum, aind filings of
platinum and gold.
Maury advised the use of the oxydes of bismuth, plati?ium,
gold, titanium, uranium, the chromate of barytes, hydro-chlo-
rate of tin, the chlorure of gold, the red precipitate of Cassius^
and tungstic acid.
M. Lefoulon believed, that by adding to the argilacious earth
of Limoges, (kaolin,) to the earth of Vanvres, already burned,
and to the petunse, or flint of Limoges, the oxydes of titanium,
uranium, manganese, gold, and the filings oi platinum, all the
desired shades, from the lightest to the deepest, might be ob-
tained.
As for ourselves, we think that with the following prepara-
tions, with which, moreover, experience has proved that the
tints can be varied by the different degrees of heat in burn-
ing, results can be obtained which will supply all our ordi-
nary wants.
First Shade. — (Yellow-grey, wine-yellow, yellow-grey-blue, in accord-
ance with the degree of heat in burning.)
Paste :
Kaolin,
3 kilog.
(6 lbs.)
Tuugstate of iron.
64 gram.
(2oz.)
Per-oxyde of manganese,
96 gram.
(3 oz.)
Oxyde of gold.
4 gram.
(1 grain.)
Enamel:
Petunse, . . 1 kilog.
500 gram.
(3 lbs.)
Oxyde of titanium.
32 gram.
(1 oz.)
* This term is used to designate the metallic precipitate of gold, which
results from the union of the proto-hydro-chlorate of tin, and hydro-
chlorate of gold, concentrated, the last in excess.
51*
406 OPERATIVE MEDICINE AND PROSTHESIS,
The oxyde of gold should be prepared as follows : Dissolve
four grains of gold in a compound of four parts muriatic to
one part nitric-acid — evaporate.
Second Shade. — (Yellow.)
Paste :
Kaolin, . . . 3 kilog. (6 lbs )
Earth of Vanvres, . 1 kilog. (2 lbs.)
Earth d'Ombre, . . 16 gram. (4 grains.)
Enamel :
Petunse, . . 1 kilog. 500 gram. (3 lbs.)
Tungstic oxyde, . 48 gram. (12 gr.)
Third Shade. — (Yellow-grey.)
Paste :
Same as the preceding.
Enamel :
Petunse, . . 1 kilog. 500 gram. (3 lbs.)
Tungstic oxyde, . 32 gram. (I oz.)
Fourth Shade.— (Yellow-blue.)
Paste :
Kaolin, . . . 3 kilog. (6 lbs.)
Oxyde of cobalt, . 16 gram. (4 lbs.)
Enamel :
Petunse, . 1 kilog. 500 gram. (3 lbs.)
Oxyde of manganese, . 48 gram. (12 gr.)
Fifth Shade.— (Pure Grey.)
Paste :
Kaolin, . . .3 kilogs. (6 lbs.)
Tungstate of iron, . 64 gram., (2 oz.)
Oxyde of manganese, . 64 gram. (2 oz.)
Oxyde of gold, . .4 gram. (1 gr.)
Enamel :
Petunse, . . 1 kilog. 500 gram. (3 lbs.)
Oxyde of platinum, . 2 gram. (36 gr.)
There is another kind of mineral teeth which many practi-
tioners find superior to those obtained by the diflerent combi-
nations of which we have been treating; these are called
transparent, and, also, English teeth. In order to give the
best information about these teeth, which has yet been fur-
OR MECHANICAL DENTISTRY. 407
nishedjwe think we cannot do better than to publish that
which we have from M. Billard, and we promise most of our
readers to notice the work* of this honorable brother, to
whom we owe some of the finest productions in the way of
mineral teeth. The different points of view in which he looks
at the manufacture of mineral teeth should interest every one
engaged in the profession, for he treats of them not only as a
manufacturer, but examines them as a practitioner. We here
give the letter which he has had the politeness to transmit to
us, and which we feel it a duty to make public :
"My Dear and Honored Brother:
" In reply to the flattering request you have made of me to
furnish you with some information about my method of man-
ufacturing teeth, I send you some facts which may tend to aid
those who propose directing their attention in this channel.
The various pastes and enamels of our porcelain manufactu-
rers, as well as for coloring, the oxydes indicated by those
who have written upon this specialty of our art, may be used
without inconvenience. The whole difficulty, which will be
met with, is in their proper combination, which should be ef-
fected with a determinate degree of heat; a defect in this par-
ticular often puts at fault the experience of the practitioner
and gives results which are altogether contrary to his hopes
and expectations.
"In my work upon mineral teeth, I have already given
some information on this subject, without, however, presenting
the formula; for to give it without, at the same time, indicating
the precautions to be observed, and the means which my prac-
tice and experience have put in my possession, to use these
formulas satisfactorily, would be to expose my readers to the
liability of failures which they would attribute to erroneous
statements on my part.
*Des dents Mineraks on Considerations gcnerales sen les Differentes Sub-
gtances Employees, etc. in 8vo. We take this occasion to mention, that M.
Billard lias practised his profession for fifteen years, which renders him
very competent authority in matters of this kind.
40S OPERATIVE MEDICINE AND PROSTHESIS,
"As a work written by you, however, should embrace all
that comes within the range of the dental art, and as you de-
sire some information respecting the new teeth, known as
transparent or mineral-natural teeth, which are now manufac-
tured. I here give you all that 1 can furnish. These kind of
teeth may be burned in an ordinary furnace, or in the fire of a
porcelain manufacturer. In the first case, where a simple fur-
nace is employed, petunse is used, to which we add a given
quantity of potassium, which may be varied from a tenth to a
twentieth part; for coloring, we use the oxydes of titanium, of
iron, (the titanium being well washed,) those procured from
the tungstate of iron, the tungstic acids and oxydes, the per-
oxyde of manganese, the oxydes of cobalt, of bromium, of
uranium, of manganese, or even ^the original mineral sub-
stances, such as titanium, the tungstate of iron, the substances
known in commerce as terre d^ ombre ^ terre de Sienne^ and,
finally, all the substances usually indicated for the coloring of
ordinary teeth. All are equally proper to give good results.
It would be superfluous to indicate the precautions with which
they should be used, for it is always necessary to combine
them by aid of the fire to the action of which they are sub-
mitted, and this can only be effected properly by frequent
trials.
"When the reverberating furnace is employed, or even the
least powerful fire of the porcelain manufacturer, silica or sand
is to be made to enter into the composition of these transparent
teeth ; this, however, it is necessary, first, to reduce to silicate
of potassium, and then to abstract the potassium by the aid
of sulphuric acid ; by this means a mineral gelatine ^ more or
less white, is obtained — the mass is then mixed in different
proportions, as may be desired, with the argiles, earths, and
coloring matters, and, if the combinations have been well cal-
culated, with relation to the intensity and duration of the heat,
to which they are to be submitted, the finest results will be
obtained.
"Such are, my dear brother, the facts in relation to the
transparent mineral teeth which I have the honor to commu-
OR MECHANICAL DENTISTRY. 409
nicate to you, and which I authorize you to publish in your
work, if you find them sufficiently interesting.
"Le Docteur Billard.
"Paris, ^pril 28, 1843."
We will close our remarks in relation to the coloring of
mineral teeth, by observing that the oxydes used, should be
reduced to an impalpable powder. For this purpose, even at
the present time, plates and mullers of glass or porcelain are
used, but, the latter material is the only kind that should be
employed. M. Billard has invented a very ingenious mill for
this purpose : it is a vase, from the bottom of which is a co-
noid projection, destined to receive the pierced bottom of an-
other vase, which is set in this one, but which does not touch
in its circumference ; the latter is turned by a handle and
grinds by its base, substances introduced between the two
vases.
Preparation and Management of the Paste. — Whatever
may be used for the composition of the base, we take a cer-
tain quantity of the paste which we have indicated above,
(mixed, sometimes, with a small quantity of covering or
enamel to give it transparency and to shade it more easily,)
to which we add such oxydes as are judged necessary, in the
proportion of thirty grains to a pound ; these are mixed with
care, keeping the mass constantly wetted upon a porcelain
table, with a muUer of the same substance; for this purpose,
glass should never be used. This is now dried as much as
possible, and made into little oblong squares, about a hne and
a half in thickness, three or four in width, and five or six in
length, these various dimensions will always be a little reduc-
ed by contraction.
At this stage of the process, little grooves horizontal or ver-
tical, and sometimes in the form of a cross are to be made on
the back face of these little squares, which are still soft, and
rounded on their lateral edges ; instead of making the paste
into these squares it is better, as we shall hereafter describe,
to mould it in forms or matrices of copper made as nearly as
possible in the form of the teeth. This groove is destined to
410 OPERATIVE MEDICINE AND PROSTHESIS,
receive the little curved platina cramps which are to form one
or more projections above the plane of the teeth, to which are
afterwards to be soldered, the gold or platina shaft, which
serves to mount the tooth.
As the strength of the artificial set depends upon the solidi-
ty of these cramps, their implantation is a part of the process
whijoh is quite important, and their preparation requires care.
They are made in several ways : sometimes a platina wire
of ordinary thickness is taken, passed through a draw-plate,
flattened and cut into proper lengths ; sometimes the wire is
simply passed through a flattener, and when it is divided the
extremity which is to be fixed in the paste is cut off with a
pair of cutting forceps. Again, finally, this extremity is divided
and the two parts turned in contrary directions.
But nothing is more variable than the form given to the
part of these cramps which extend above the paste. Some
put two, three, or four of them, terminating, exteriorly, by as
many isolated projections, sometimes placed upon the same
line, sometimes distributed in equal or unequal numbers on
each side of the groove. Others curve them outward, in the
form of one or even two rings destined to receive a little me-
tallic shaft, either vertical or horizontal ; others, again, fix to
the cramps a little groove, also of metal, which makes one with
them, filling the groove in which they are buried, and is des-
tined, as the rings just described, to give attachment to the
metallic shaft upon which the teeth are to be mounted. Some
manufacturers are contented to leave these cramps simply at
the bottom of the groove in the paste and afterwards to solder
the shaft upon their external face.
We have indicated the various methods of arranging the
cramps exteriorly because they are those which are followed
at the present time ; but it is evident that, for the most part,
they are defective, and for these reasons : when a tooth is to
be mounted, it is necessary to solder the metallic shaft, which
is introduced between these cramps ; now, this is one more
heating of the tooth than is necessary, (for, of course, this
soldering does not obviate the necessity of again resorting to
the same process to fix the tooth to the plate,) and this com-
plicates the operation.
OR MECHANICAL DENTISTRY.
411
To obviate these inconveniences, we have fixed in the paste
before burning, not simply cramps, but, apiece of metal, form-
ing at once the cramps and the tenor or shaft by which the
tooth is to be fixed to the plate. This fixture is composed of
a central shaft, from each side of which go off, in the form of
wings, little cramps which pass into the paste and disappear
in it. Fastened in this manner there is no risk of the fiiture
becoming defective by the vice of one of these cramps, all
being attached to and making one with the principal piece ;
this is not the case with the old method in which it was suf-
ficient for a single hook to become detached from the shaft to
compromise the solidity of the whole. As experience has de-
monstrated to us the advantages of this procedure, we advise
our professional brethren to adopt it.
M. Billard* maintains, that the method of manufacturing
mineral teeth, so that a piece of platinum occupies the place of
the groove intended for the cramps, seductive as it appears, is,
however, defective, because the piece of platinum when the
tooth is burned, will, in consequence of the expansion of the
metal, in opposition to the contraction of the paste, cause the
latter to crack. We beg pardon of our honorable brother, to
whom on all proper occasions, we have, heretofore, rendered
justice, but we have facts to prove that this objection has no
force, for out of a thousand teeth, thus made, sometimes
scarcely two are found cracked. Reason, too, demonstrates the
same, for the dilatation of the metal compensating for the con-
traction of the paste, the relations of the two parts remains the
same ; and if, against all probability, however, this contrac-
tion should exceed the expansion it will only be the su-
perficial layers which will not be completely in contact with
the metal ; but on the one hand the visible part of the cramps
serves to keep the paste sufficiently united to the metal, Avhich
it covers, a little, and, on the other side the cramps are not
less firmly fixed for giving the piece the necessary solidity
than if they were mounted by another method.
The best proof besides, that, in our method, the paste does
* Work quoted.
412 OPERATIVE MEDICINE AND PROSTHESIS,
not separate from the metal during the burning, and that the
tooth does not crack, is, that, generally, the metal is fixed,
like a kernel in the paste, and that if the external layers on this
side have some flaws they can be most easily removed by the
grindstone.
Mineral Teeth vnth a Talon. — The implantation of the
cramps in the posterior faces of mineral teeth, is intended for
those, only, of which this posterior or internal face is flattened,
and which form rather simple /acac^es of teeth, than entire
teeth ; but mineral teeth are often made to resemble, in all points,
at least of the crown, the natural teeth ; that is, they are furnish-
ed behind or interiorly with a lalon or heel. This heel is
formed in three ways : either by making it continuous with
the crown before burning, adding it with a substance of the
same nature after it is burnt ; or, finally, making it with a me-
tallic substance soldered to the cramps of those teeth of which
we have just spoken, as being most commonly employed.
The first method is simply to construct a tooth precisely like
a natural tooth, (an incisor or canine,) in form, and, in the
thickness of the projection backward, upon the middle of the
upper surface, to make a vertical hole ; in this hole are fixed
the cramps destined to be soldered to the shaft or pivot which
is to fill this hole, or to a little metallic tube to receive the
shaft. The greater part of the transparent or English teeth
are made in this way.* The force of adaptation which holds
these tubes united to the paste, after the burning, is another
proof that the objection which has been urged against our
cramps is not well founded, for this tube, in consequence of
its form, is more liable to dilate by the action of the fire and
crack the substance in which it is placed, than a little simple
piece of metal ; yet, fi'ora this cause, the teeth are never
cracked.
• To make these tubes, a band of platina is used, the edges of which are
brought together by passing it through a draw-plate. M. Billard, pro-
poses to make them of a band of platina, one line in width, turned in a
spiral form. It may be observed, that the tube could be made in a single
piece, but then it would be more costlv.
OR MECHANICAL DENTISTRY. 413
By the second method the pivot is first soldered to the
cramps of the common plate tooth ; after this is done, the pro-
jection, which gives it the form of a perfect tooth, is added :
the substance of which this is made, is composed, according
to the formula of M. Delabarre, as follows : Porcelain paste,
seven parts ; calcined gypsum, one part; white sand, one-twen-
tieth part of the whole mass; such oxyde as may be desired,
four ounces, six grains, to the two pounds. As the addition
of gypsum greatly augments the fusibility of this paste it is
entirely unnecessary to resort to the furnace of the porcelain
manufacturer, a simple air-furnace is generally sufficient. We
regard this method as very defective, first, becaiise the paste
added is united with difficulty to the first, from which it is sepa-
rated by a piece of platinum, then, not being as Avell burnt as
the tooth itself it will be less able to support the shocks to
which it will be subject. It is, therefore, a much more simple
and certain process, when these teeth are required, to make
them at once of the desired shape, or to make the projection of
platinum, and solder the pivot to it.
Whilst some authors have exaggerated the advantages of the
pivot teeth, others have improperly proscribed them entirely.
These latter, to support their objection, give a very bad rea-
son in saying, that the heel renders them difficult to mount,
because, in so delicate a question as the insertion of artificial
teeth no difficulties of this kind should be regarded when the
result will be advantageous ; and they condemn our art in de-
claring, that the teeth we have been describing, continually
receiving the shock of the increasing lower teeth, are shaken
and loosened, as this difficulty could be readily avoided by
making the projection less than the usual size, or by grinding
it down, so as to prevent any possible shock capable of pro-
ducing injurious effects.
The question of the utility of mineral teeth with a talon^ can
only be determined, therefore, when the cases in which they
may be advantageously employed can be established. An at-
tentive examination of this question has brought us to the fol-
lowing conclusions : the flat teeth, suffice perfectly, in general,
when they are to be mounted upon the front part of a metallic
52
414 OPERATIVE MEDICINE AND PROSTHESIS,
plate ; but a tooth, with a talon, will be found useful in replacing
single tooth, particularly in the lower jaw, because, when
mounted on a pivot, they cover the entire roots, and then the
tongue finds no unpleasant breach, and nothing can get be-
tween the root and the artificial tooth.
Alolar Mineral Teeth. — All that we have said of the proper
form to be given to mineral teeth and the various methods of
attaching them, has relation to the canine and incisor teeth,
only; but molar teeth are also made, the form of which vary
according as they are to be mounted in front of the exterior
border of the plate, or base, destined to receive them, or imme-
diately upon this plate. In the first case the artificial tooth is
formed precisely like the natural one, except the lingual side,
which is left flattened. Tiiis side is fiirnished with cramps
exactly similar to those intended to replace the incisores. In
the second case they are made in all points like the natural
teeth. The question now arises, how are these teeth to be at-
tached to the plate? In several ways:
1. In each of the sides of the tooth, corresponding to the
dental interstices, a depression is made, into which the cramps
are fixed; 2. A vertical hole is made which passes nearly up
to the surface of the crown; into this passes a pivot fixed to
the plate, and through the upper part of this pivot a pin is in-
troduced horizontally through a little hole previously made for
this purpose ; 3. The tooth is pierced with a horizontal hole,
near the top, through which a platina wire is passed, bent
down to the plate on each side and soldered ; 4. A vertical
hole is made entirely through, larger toward the crown than at
the base ; a pivot is fixed to the plate and passed through the
hole, the top of the pivot is capped, and the whole soldered to-
gether, thus fixing the tooth. This last method is recom-
mended by M, Lefoulon,* and is, certainly, the most defective
of all, because it has the great objection of leaving upon the
grinding surface a large and very visible spot. It will be re-
plied to this objection that the same is the case when a de-
cayed tooth is plugged on the grinding surface; but in this
case, no choice of means is left with the artificial teeth.
• Ouvrage cite, p. 417.
OR MECHANICAL DENTISTRY. 415
Sometimes a piece comprising two or three molar teeth is
made. In such case a hole is pierced through the middle one,
destined to receive a pivot soldered to the plate ; in the two
others a groove is made into which pivots pass to keep the
whole piece in place * unless it is preferred to make the
grooves on the lingual or internal side and solder it, like the
incisor teeth.
Preparation and Manner of Using the Enamel. — To make
enamel, as much of the mass already described, as is desired,
is taken, and to it is added, such metallic oxydes, or such a
combination of them, as is necessary to obtain the desired
shade; in quantities of about an ounce at a time, grinding the
whole, perfectly, upon a porcelain table in order to distribute
equally the coloring matter. In order to obtain a color more
homogeneous to the enamel, we may use, with advantage, a
paste made of an enamel already burned, and broken up
in a mortar. This may be regarded as a color already well
formed.
The enamel paste should be ground with more care than
that of the base ; the more perfectly this is done the more free
will be the surface of the tooth from spots, and the more uni-
form will it appear. It may be preserved in water, if the pre-
caution be taken to remove it from time to time, and it be used
at about the consistence of a thick paste; and, in order that it
should attach itself to the earthy base it should be diluted with
water in which some gum arabic has been dissolved; finally,
it is applied in a thin layer, if the base is colored, and in a
thicker one if the contrary is the case.
This application of the enamel to the paste is made in two
ways : either by first putting the ena,mel in the mould, and
then the paste, making the groove and fixing the cramps after
this is done; or, on the contrary, the tooth is first moulded,
the groove made, the cramps fixed, and then the enamel ap-
* For the better comprehension of what we mean by the anterior and
posterior surfaces of the molar teeth, we will remind the reader that they
are those which correspond to the dental interstices ; the two others are
the lingual or internal and the external which corresponds to the cheek.
416 OPERATITE MEDICINE AND PROSTHESIS,
plied. The first plan which has been longest in use is defective
in this, that the paste, placed upon the soft enamel, buries
itself always more or less by its own weight and by the pressure
necessarily occasioned by making the groove and fixing the
cramps; the inevitable result is, that the layer of enamel is very
unequally spread over the surface of the tooth. This may be
proved by grinding half away two teeth enamelled by these
two plans, in one the paste will be seen to describe a regular
curved line, whilst in the other it will be irregular. The se-
cond plan, although less varied, easy, and, perhaps, a little
more certain in the fire, is, however, always preferable; it is
the one we always adopt, and which is recommended by those
who are most versed in the manufacture of mineral teeth.*
Manner of Burning mid of Uniling by means of the Fire the
Base and Enamel. — When the teeth (formed in the mould)
£ire sufficiently dry, and the enamel has become adhered to the
paste, they are put in the furnace, being previously arranged on a
gazette,-f sprinkled with sand, side by side, but sufficiently
distant from each other to prevent them from touching as they
would become adherent from the fusion of the enamel, during
the burning, if this were allowed. It is also indispensable, that
the face upon which the enamel is spread should be placed
horizontally as, when it liquifies, it will always run down to
the lowest part.
It has for a long time been believed, or pretended to be be-
lieved, that no one could make mineral teeth but those who
were living in the vicinity of manufactories of fine pottery, or
those who possess large furnaces. This is an error which
those dentists, who hope to make a monopoly of this manu-
facture, are very careful not to attempt to remove; it is, how-
ever, demonstrated now, that a small furnace, with a hearth
eight or ten inches in diameter, twelve or fifteen deep, fifteen
to eighteen high, is quite sufficient for this purpose. These
furnaces can be obtained ready made or may be constructed
of bricks.
•See on this subject the work of M. Billard, already cited,
t A species of plate made of refractory earth.
OR MECHAMCAL DENTISTRY. 417
These furnaces being constructed, and arranged with the
necessary apartments and muf&es, to prevent the teeth from
contact with the combustible material, and charged with char-
coal, it now becomes important to be able to ascertain exactly,
from time to time, the condition of the teeth, for no certain cal-
culation, from the duration of the burning or the quantity of
combustible material used, can be made, since the amount and
intensity of the heat may vary according to the state of the
atmosphere. For this purpose recourse is had to various
means : 1. To ascertain by a platina calorimeter, the degree
to which any composition has been heated ; by the use of a
Wedgewood pyrometer, by means of which the degree of heat
is ascertained by means of pieces of alumine, drawn from time
to time from the furnace and applied to the scale of the instru-
ment; 2d. By fixing samples of the composition to platina
wires, placing them in the common apartment of the furnace
and withdrawing them from time to time. This last process
being the most simple and economical is that to which we
give the preference.
It will be known, when the paste is approaching the proper
degree of burning, when the samples, which should be taken
alternately from below and from the middle, have assumed a
pale yellow color, can no longer be cut away with the file, and
have taken the semi-transparency of porcelain ; the fire should
then be gradually extinguished by turning down the grate of
the furnace. If the composition is withdrawn too soon, before
the enamel is vitrified, it will be rugged and change in the
mouth ; if, on the contrary, it is allowed to remain too long,
the color becomes paler, the enamel evaporates, and, finally,
becomes black or is burnt. It should not be forgotten that the
teeth should be allowed completely to cool in the receptacle in
which they are burned, for if they are withdrawn they will
crack and even split to pieces on being suddenly exposed to a
cool temperature.
But even when guided by these principles, it will be neces-
sary to make many trials ; trials, too, surrounded with decep-
tions, before success can be expected. The manufacture of
mineral teeth is composed of so many elements, that in a work
418 OPERATIVE MEDICINE AND PROSTHESIS,
of this kind, devoted, as it is, to the general principles of onr
art, only simple generalities should be presented, The de-
tails are, indeed, so difficult to master fully that it is not always
done even when the processes are seen. We believe, therefore,
after having given a recapitulation of ourknowledge on the sub-
ject, that we cannot do better than to quote, in justification of
our position, what has been said by M. Billard in relation to
the difficulties attending the manufacture of mineral teeth.
"The fabrication of mineral teeth does not consist, princi-
pally, in knowing the substances, primary or secondary, which
are used, as the paste and enamel, but those which give their
proper quality to these teeth, rendering them harder, more com-
pact in their interior, little liable to break or be injured in the
fire. Upon these points it is particularly difficult to impart
any profitable instruction. There are, besides, other difficul-
ties attendant upon particular locahties: thus, the paste and
enamel of which I make use are obtained from the porcelain
manufactories of Paris; I prepare my compositions to be burnt
in the furnaces of these establishments, because my pastes and
enamels being the same as those used in the factories, the heat
is just in the proper relation— I only add thesubstances which
give them the proper color, and render them harder, without
making them more or less fusible than in their original condi-
tion. Dentists living at a distance from Paris would, there-
fore, be deceived, if 1 were to attempt to present any rules to
guide them, as these could not be general ; for, in the different
manufactories, the pastes and enamels are combined differ-
ently, and bear more or less perfectly the substances which it
is necessary to add in the manufacture of teeth. Thus,
any thing I might say in relation to the substances which
ought to be used in making proper pastes and enamels could
not be correct, since the earths used differ in France, England,
Germany, and the United States, and in different parts of the
same countries, as the differences between the porcelain manu-
factured in these places shows. In different countries, then,
each manufacturer should modify his composition. Finally,
I alwaj's manufacture, myself, the substances I use in making
my compositions and 1 am thus enabled to know, exactly, the
OR MECHANICAL DENTISTRY. 419
quantity of mineral or metah I incorporate with it; this can
never be the case when these articles are purchased, already
prepared, as, for instance, the oxyde of gold, as the salts, or
precipitating metal, enter in a certain weight, in greater or less
proportions, it is impossible to know exactly the amount of
coloring metal which it contains."
Manner of Finishmg Mineral Teeth. — However near in
form to the natural teeth may be those matmfactured accord-
ing to the rules which we have laid down, it is very rarely the
case that we are able to use them as they come from the fur-
nace, or rather from the mould, for they undergo no alteration
in burning. It is vain that they are selected from the same
classes they are intended to replace, that is, incisores for in-
cisores, canines for canines, and so on ; it will always be found
necessary to reduce them somewhat in size, either to render
them more like .the natural teeth near which they may be
placed, to accommodate them to the vacancy they are to fill,
or, finally, to fit them to the bases upon which they are
mounted. For this purpose a small lathe grindstone, mounted
in the usual manner, is used. This stone is, generally, about
from eight to twelve inches in diameter. Some dentists, Maury,
for instance, recommends one from twelve to twenty inches,
while others are satisfied with a stone much smaller, from six
to eight inches, which they turn with the hand. Both are in
error: the first, because the stone recommended is of too great
dimensions, is inconvenient, and will never cut, regularly, so
small an article as a tooth from which there is, sometimes, so
little to be removed that a half revolution is sufficient to effect
it; the second, because so small a stone would cut too slowly.
In all cases, however, whether these stones are large or
small, their circumference is cut into ridges, by means of a
piece of steel, or the point of a bad file ; these ridges enable
the dentist to cut away the tooth in every part, and in every di-
rection. Finally, they turn vertically, and the lower edge is
plunged in a trough filled with water; upon this trough is a
little cover to catch the teeth when they slip from the hand, it
is pierced with holes so as to allow the water to pass back into
the trough. In addition to these stones, it will be found useful
420 OPERATIVE MEDICINE AND PROSTHESIS,
to have one about six inches in diameter, and about four lines
in thickness, mounted in a similar manner to those used by
glass-cutters and lapidaries; it is moistened so as to answer
the desired purpose. As to the stones of sbft iron or steel-
plate, which some authors praise so extravagantly, we hardly
think they are necessary; we should prefer the little vegeto-
mineral stones, recommended by M. Billard, if experience did
not convince us, every day, that the ordinary stones, rendered
familiar by constant use, answer almost every purpose.
It is necessary, sometimes, to remove small portions which
cannot be reached by the stone, this is done by means of a
file charged with a species of sandstone slightly moistened.
For some time, too, round files of a composition nearly
resembling the vegeto-mineral stones of which we have just
spoken, and which are both nothing more than pieces of wood
or iron, covered with gum lac, charged with emery. If the
mineral teeth are too much rounded on the external surface,
this part may be ground down on the stone, and after-
wards polished with wood sprinkled with finely pulverized
pumice ; and to render the pohsh more perfect, pumice still
more finely powdered is used without being moistened, as in
the former case.
Finally, a part of the upper surface of the anterior part of
the incisor and canine teeth may be cut away, by means of the
file and stone alternately, for the purpose of fixing a piece of
red wax with which some persons are satisfied to imitate the
gums.
4. Recapitulation of the Qualities of the Substances used in the
construction of Artificial Substitutes, and the cases to which they
are Applicable. — Authors and practitioners are very well agreed
at the present time, in relation to the substances used for arti-
ficial teeth, and advise the use of human teeth, the ivory of the
hippopotamus tusk, and mineral teeth; but few among them
venture, formally, to give the preference to any, or even to in-
dicate the cases to which they appear to be particularly appli-
cable. It is important, however, in order to prevent the young
practitioner from making fruitless attempts which would com-
pel him to incur expense and compromise his reputation, that
OR MECHANICAL DENTISTRY. 421
he should be enabled to have general rules, in relation to the
subject, constantly in his mind. We will, therefore, present
what reason and experience have demonstrated to us.
When a single tooth is to be replaced, the hippopotamus
tusk is least suitable for the purpose ; for when deprived of
its enamel, it quickly becomes yellow, and if the enamel is
allowed to remain, it can never be made to accord with the
adjoining teeth. In such cases, therefore, we give preference
to the natural teeth, and sometimes to the mineral teeth ; to
the first, in general, when a single tooth is to be pivoted on
the natural root, and when there is room enough for llie back-
ward projection; first, because it is easier to find a tooth which
will accord, perfectly, in form and color with the adjoining
teeth, and because the heel continues perfectly back of the cur-
vature of the alveolar ridge ; to the second, when the superior
jaw, or for the inferior in the case of a menton de galoche^ (jii^i-
ber-jaw,) there is not room for the heel in consequence of the
length or situation of the antagonist tooth.
When a continuous series of artificial teeth are to be insert-
ed, due regard being had to what we are about to say in rela-
tion to the matter, natural or mineral teeth may be used indis-
criminately, but where the series is interrupted by the presence
of teeth still remaining, that is, where they will be between
the artificials, natural teeth are best, as they can always be
found better to accord in color with those which remain. We
are very well aware that this is not the opinion of the partizans
of mineral teeth ; as they regard them as so much better, that
there are few cases, and some go so far as to say, that there is
not a single case, in which the preference should not be given
to them. The following extract will show their views in rela-
tion to the subject.
"If you desire to select a mineral tooth which will perfectly
correspond to the natural tooth which is next to the vacancy
to be supplied, you will cry out against the imperfection of
the invention to meet your wants, and you have reason to
do so ;* but now take a natural tooth for the same purpose and
• Metnorie cite, p. 8 et suiraaies.
422 OPERATIVE MEDICINE AND PROSTHESIS,
do you suppose you will escape difficulties? First, you must
find a tooth bearing an exact resemblance to those which re-
mains, and it is excessively difficult to find one precisely similar
in form, in dimension, and in the direction of its lines ; it be-
comes necessary to alter the shape of the tooth, you will cut
down its edges, perhaps you will round or flatten its surface.
Then you will have failed in attaining your object, for it will
no longer have a natural form, and will easily be distinguished
in the mouth. With a natural tooth which precisely resem-
bles the one you wish to replace, you will encounter difficul-
ties of another species : the dental canal, if it is a pivot tooth
you are inserting, will be of a difierent size from that of the
dental canal of the root, and you will find that it either projects
beyond, or sets further in the mouth than the adjoining tooth ;
the setting of a natural tooth, is therefore surrounded with
more difficulties than the setting of a mineral tooth. Another
difficulty may present itself with a natural tooth ; if you have
not allowed it to remain at least a day in water, before select-
ing it, it will afterwards acquire a different shade from the
other teeth to which, when first inserted, it may have corres-
ponded precisely."
We perceive, in this comparative view, that the advocates
of the mineral teeth are at least as much embarrassed to find
objections to the natural teeth as to overcome the difficulties
attendant upon their insertion. Let us see if their objections
are well founded. These objections rest upon the difficulty
of matching them with teeth remaining in the mouth, the ne-
cessity of altering their size atid shape, the diversity of the
dental canal of the artificial tooth and the root upon which
it is to be pivoted and finally the necessity of selecting the
desired tooth from among such as have been tempered in
water previous to the selection.
As to the difficulty of finding a tooth to correspond pefectly
to any natural teeth which may be remaining in the mouth, it
can only exist with those who have a small number of teeth
to select from, or who have acquired the bad habit of procur-
ing for their use, such teeth only as have a fine and beautiful
shade, rejecting all others. As to the necessity of altering
OR MECHANICAL DENTISTRY. 423
them in size or form, by grinding, this can rarely occur with
those who have a large niinnber to select from, and even if it
should be found desirable, it should always be taken away
from parts which are not visible, and never from the anterior
face. The only remaining objection against human artificial
teeth, then, is the difficulty of fitting the central canal opposite
to that of the root; this, of course, is confined to pivot teeth,
and can be obviated by a stroke of the file making the pivot
larger in some particular direction, by including the tooth,
by arching it, or making the pivot diverge from a straight
line.
The objections to mineral teeth, rest, unfortunately, on bet-
ter grounds. We will say nothing here of their fragility
which is feared by persons, only, who are ignorant of their
composition, nor the difficulties which are found in mounting
them, as these soon are overcome by practice ; but there is pecu-
liar brilliancy, especially in the light, which, for the most part,
prevents their being inserted next to any teeth which may be
remaining in the front part of the mouth. We are well aware,
that this excessive brilliancy may be lessened and even re-
moved entirely by the grindstone ; but there is danger of fall-
ing into an opposite difficulty, and it becomes necessary for
the tooth to be covered with saliva in order to recover the ne-
cessary brilliancy, but it always remains unpolished, and is
readily tarnished. This objection, it is true, holds only for in-
terrupted sets, for when there is a continuous set, the brilliancy
is uniform and not unpleasing. But it cannot be contested, for
it can be shown, indeed, from the avowal of advocates of the
mineral teeth, that it is difficult for very nervous persons to
become accustomed to the friction and shock of two substances
of this nature. M. Billard, who is pre-eminent for having ex-
tolled teeth, cites the case of a person in whom, "the contact
of a metallic plate (covered with mineral teeth) produced a
sensation of cold and numbness, resulting from a continual
disengagement of galvanic fluid produced by the mixture of
metals, and which in spite of the efforts which were made to
become accustomed to the set of mineral teeth, which were
preferred to those of any other kind, the patient was at last com-
424 OPERATIVE MEDICINE AND PROSTHESIS,
pelled to resort to a set carved from ivory." We have many
times met with similar phenomena.*
For the construction of complete sets, the ivory of the hippo-
potamus tusk is a precious substance, the advantages of which
no one will dispute. First, it is very easy to work, and if the
color changes in time, the change is so regular and uniform as
to offer no unpleasant contrasts of different parts of the set.
This substance is particularly valuable, too, for the purpose of
making bases upon which to mount either natural or mineral
teeth, particularly with persons who find it difficult to accus-
tom themselves to artificial sets. Nevertheless, very excellent,
entire and partial, sets of mineral teeth are put up on metallic
bases, and this method is the only one suitable for those per-
sons in whose mouths the fluids are of such a nature as quick-
ly to injure the natural teeth, or those made of hippopotamus.
Young practitioners should also be made aware, that they
will meet with sensitive persons who will obstinately refiise to
wear human artificial teeth. It is certainly a prejudice which
causes this repugnance, but we cannot see that any thing is
to be gained by combatting it, it is better, in our opinion, to
conform to the wishes of such patients ; the most important
thing we have to do, indeed, is to consult the tastes of our
patient when they do not demand anything which would con-
flict with the principles of our art.
We are confined, in our efforts, to repair the losses of nature,
to human teeth, those made of the hippopotamus tusk, and
mineral teeth, such as they are at thep resent day. But if
our efforts in approaching nature very nearly have been
quite happy, we have not entirely succeeded ; and even if
nothing should be wanting as regards the imitation of nature,
still there are always improvements which ingenuity and
economy will prompt.
* As this effect may, perhaps, be attributed to the simple contact of the
plate with the gum, we would observe, that, even if the fact, that the re-
sult is infinitely more rare when the plates are surmounted by natural
teeth, did not render the matter indisputable, the phenomenon readily
finds an explication in the diversity of metals in the plate and teeth. See,
for more ample information in relation to this subject, the Traite de Phy-
sique Medicale de M. Pelletaw, etc. etc.
OR MECHANICAL DENTISTRY. 426
To speak only with regard to mineral teeth, would it no
be desirable if some person out of the dental profession, bu
scientifically acquainted with the manufacture of pottery, glas;
and porcelain, should travel out of the beaten track, and bt
enabled to dispense with kaolin as a base ? No doubt, then
but that he would find, in some compound, fuller's earth, pro
vided it would become white in burning, as pipe-clay, with ai.
infusible sand very much divided, and a small quantity o
white glass, adding a proper and sufficient quantity of the me-
tallic oxydes, a mixture, as M. Delabarre judiciously remarked
twenty years ago, for making teeth which would be so much
the more solid, as they could not be burned except at a ver>
high temperature.
Section 2. — Of the Metals used in the Dental Prosthesis.
The first of all qualities which metals, destined for the pur
pose of uniting and fixing artificial teeth in the mouth, should
be, that of remaining unchanged when exposed to the action
of the saliva and the various fluids which are secreted from the
mouth and digestive passages ; for, undergoing a change from
the action of these agents, salts may be formed which will ex-
ercise a dangerous influence on the health; for instance, if cop-
per were used, verdigris would be produced, and silver would
oxydise; and even if the change undergone were not inju-
rious to the health, the metal itself is as liable to be destroyed
as iron.
We have two metals, which are used in preference to an}
other, and these possess those desirable qualities, and have
besides, the advantage of being firm enough to offer all thi
necessary resistance, and still malleable enough to be easily
worked: these metals are gold and platina. Silver, alone, should
never be used, because the gas coming from the lungs possesse.'
the property of blackening and changing it to a sulphuret
which produces a strong and unpleasant taste in the mouth.
As it is, besides, too soft for the purpose, in its pure state, tht
addition of some copper is necessary to diminish its malleability,
and this would make it dangerous ; it should never be used.
53
426 OPERATIVE MEDICINE AND PROSTHESIS,
indeed, even for the purpose of fixtures which are to remain
in the mouth, temporarily, as those intended for the correction
of irregularities, and the fixing of loose teeth. Practitioners
of the last century, and even those at the commencement of
this, have recommended silver for such purposes, as is proved
by the sentence of Fauchard which follows: "If teeth should
lean too much out of their proper position, and cannot be held
by a thread, it is necessary to make use of a plate of gold or
silver;''^* and this, from Laforgueif "Gold, platinum, or silver,
should be annealed to prevent them from breaking, and yet be
hard enough not to bend when they are buried in the roots."
Of Gold and of its Use. — The ancient dentists employed,
for dental prosthesis, gold, almost to the exclusion of all other
metals. Its beautiful color, its ductility and the facility with
which it may be mixed with other metals, in order to render
it a compound susceptible of being employed, gave it certainly
a preference over all other metals until the discovery of platina.
We find it in cotfimerce in a pure or alloyed state. Pure or
fine, is called twenty-four carat gold.J Many pieces of money,
as the ducats of Hanover, of Denmark, and of Holland, are
nearly of this kind; but in this state it is so ductile that it
yields to the slightest pressure; it is this kind which we em-
ploy, reduced to thin leaves, for plugging the cavities of de
cayed teeth; but in wire for hgatures, pure gold, united in
certain proportions with silver, forms what is called green gold ;
it is necessarily more consistent than fine gold, but it is ren-
dered still more hard by being united with copper.
For commercial purposes gold has three legal proportions :
The 1st, is to 22 carats /^nds, \.
The 2d, is to 20 carats /^nds, \.
The 3d, is to 18 carats 000.
* Ouvrage cite, tome ii, p. 96.
fOuvrage cite, tome ii, p. 17.
f The word carat comes from the Arab /cj/raf, (weights which are worth
ia Mecca the 24ih part of a pennyweight.) It expresses, in our language,
the degree of purity of gold, and always denotes, whatever may be the
quantity of this metal, the 24th part of its mass. Gold, supposed per-
/ec% /)M)*e, is 24 carat gold ; if the metals thai We have alloyed with it
are one twenty-fourth, it is only 23, and so ou.
OR MECHANICAL DENTISTRY.
42T
This last standard is that which jewellers generally employ
in the manufacture of jewelry, as we see, three-quarters only
is pure gold, and one-quarter of alloy or brass. This gold has
a reddish color, and is altogether harder than the other and
finer qualities ; when rolled and hammered, it is very elastic
and resisting, and may be used for clasps and resorts; but it
is not sufficiently soft to be used for plates for teeth ; for this
purpose we are obliged to employ gold from nineteen to
twenty carats fine; in this state it preserves its beautiful yellow
color, oxydizes but little, and has nearly the consistence of
platina.
In large cities, dentists can easily procure all the gold which
they need ; but in small cities, and even in those of ordinary
size, they have not this advantage, and cannot procure it from
the jewellers, for they have it fabricated and stamped, or not
fabricated, but then only eighteen carat gold; they can use the
difierent pieces of money met with in commerce, and whose
exact standard they should know in order to add the exact
quantity of brass necessary for the purposes for which it may
be designed. French coin is between twenty-one and twenty
carats; the English coin is more than twenty-two; conse-
quently, we reduce the first to the standard most frequently
used, by adding a twentieth of brass, and the second by add-
ing a greater quantity.
From the following we observe the manner of proceeding.
If we wish to have gold twenty carats, we take a piece of 20
francs, which is 21 carats -^f , and which weighs 6 grammes,
5 decigrammes, we add to it 67 centigrammes of brass ; if we
wish to have 18 carat gold, we add to this piece of 20 francs, 1
gramme, 5 decigrammes, etc. etc. We hammer the two metals
into little pieces, and we place them in a Hessian crucible, or
one of any other fabrication, we then add a little borax : we
place this crucible in the midst of a coal fire ; then cover it
with a piece of tile, and blow the fire, strongly, with a
bellows about half an hour. If, at the moment, we uncover
the crucible, we see the metal melted and brilliant ; we then
take this crucible with a pair of tongs, and turn the gold into
an iron receptacle which we call an in^ot mould, which we
428 OPERATIVE MEDICINE AND PR0STHESI3,
have had the precaution to heat and to rub with a greasy body
as oil or tallow. When the product obtained is cooling, we
forge it with a hammer, on an anvil, first in one, then in
another direction, heating it from time to time to a red heat,
until it is forged into the form we wish it to have.
We perceive that the operation has succeeded when the gold
is ductile, or forges without cracking. When the ingot elon-
gates its molecules heap up more and more, or, in other words,
the metal settles. We make it into wire or plate according as
, we wish to have it. But in this case we are obliged to heat it
Dften to a red heat, this we call annealing, in order to keep it
soft or ductile, so as to prevent it from breaking or cracking in
elongating it.
We will add, although it may be known to every one, that
'he method of testing in a brief but ready manner, the differ-
3nt standards of gold, consists in tracing two or three lines
with the object we wish to test, upon a black and hard flint,
known under the name oi touchstone ; then we plunge a long
crystal stopper into a bottle of nitric acid, known in commerce
under the name of strong water, and touch the traced lines,
[f these lines preserve their yellow and metallic brilliancy, we
infer that the gold has its legal standard, namely, eighteen ca-
rats. If, on the contrary, the line takes a reddish brown color,
like brass; and if a great portion is removed, we conclude it
IS of an inferior standard, and lower in proportion as the trace
is more readily removed.
Platina and its Use. — It has not been a century; since pla-
tina, (vulgarly called vhite-gold,) has been known, and it has
not been more than forty years employed by dentists. Its dis-
covery and introduction in the arts has been a valuable re-
source, because it preserves great consistence, although very
malleable, and it is least of all mineral substances affected by
chemical agents, and by the buccal humors.*
* The deep and cloudy tint platina sometimes acquires in the month of
some persons affected with certain diseases is not a true oxydaiion, for the
metal does not lose its polish, the slightest rubbing will restore its ordi-
nary brilliancy.
OR MECHANICAL DENTISTRY. 429
This precious mineral, is valued not so much for its real
value, since, at the present day, it is not worth more than a
third as much as gold, as for the service it renders, is found in
many parts of the East Indies, principally at Choco, Barba-
doeSjSt. Domingo, Brazil, and even in many parts of Siberia.
It is usually found in small flat grains, containing besides pla-
tina, a very great number of metals j more of sulphur, of
silex, etc. We meet with it, however, sometimes, weighing
from a half to one kilogram. When it has not been forged,
its specific gravity is 20.98, (that of gold being 19.257;) it is
not as good a conductor of caloric as silver or brass.*
When pure, platina is of a grey color, which equals the bril-
liancy of silver. This metal resists the action of the most
violent blows of the forge, and is not affected by any of the
simple acids; it resists even the action of cold mercury, which,
in this state dissolves silver, gold and brass. Furthermore, it
being about a twentieth heavier than gold, we would prefer it
to this latter in the construction of artificial pieces, not being
liable to melt by the action of fire, it can be worked with more
facility than any other metal, because we can always solder
together two parts of platina with gold or silver, whatever may
be their standards, and because we can employ many different
solders upon a plate withouft melting or difi'using it.
We make with platina and gold, cast in a very intense fire, in
the proportions of a fourth of the first, and three-fourths of the
second, an alloy which has a clear rose color, which renders it
more convenient for ligatures, because it is less apparent and
more tenacious than gold or platina alone.
M. Delabarre, finding that 20 carat gold, and even platina,
alone, are too ductile for certain purposes, as thin plates, and
which he wished to have as solid as 18 carat gold, has pro-
posed to make a double plate of platina, which has all the solidity
of this latter, without having the unpleasantness which the
fourth of brass, which enters in its composition, communi-
* See, for more ample details of this mineral, Vacquelin, Berzelius,
Davy, Lausier, Dumas, Orfila, in their general treatises on Chemistry.
53*
430 OPERATIVE MEDICINE AND PROSTHESIS,
cates, and which, without rendering it dangerous, gives a
brassy taste. In order to accomplish that, he placed a very thin
gold plate, 20 carats fine, between the two leaves of platina, fast-
ened them by two rivets, and soldered them by the fusion of
the intermediate leaf. It then being reduced thoroughly, com-
posed the necessary thickness.
These plates might have the advantage'; but as dental pros-
thesis has many more difficulties to overcome, and greater,
assuredly, than those which belong to the working of metals,
we would advise our young professional brethren to employ,
in making plates, platina, which possesses sufficient properties,
and to never forget, that in dental prosthesis, the construction
of pieces is not the only object, but that their adjustment, and
the opportunity of their application is the principal end ; it is
of this that we shall now treat.
We should not, however, omit to say here, that palladium
is, also, an excellent metal for making very light plates. Being
equally pure, it comes not so dear as platina; for being lighter,
it gives, all things equal besides, a greater surface. It has,
however, over this latter metal the inconvenience of being
harder and of oxydizing. We are astonished that dentists
have not oftener employed it.
Soldering of Gold and of Platina. — Every one knows that
we call soldering the operation which has for its object the
union of any two metals, or rather, the forming of one by means
of another metal which we employ, so to speak as a cement.
Three conditions are necessary in order that this operation
shall succeed ; the first is, that the metal which we employ to
form the union, must be fusible at a lower temperature than
those which are to be united, or shall be most effected by the
fire during the operation ; the second is, that these metals
must be sufficiently heated in order that their molecules may,
if not in the deep layers, at least in their superficial ones, be
penetrated by the intermediate metal: the third is, that the fu-
sion of this metal must be aided by the action of another sub-
stance ; for this we use borax, (sub-borate of soda.) Gold and
platina being, as we assert, the two, not to say the only two,
OR MECHANICAL DENTISTRY. 431
metals employed in mechanical dentistry at the present day,
they are the only ones we shall treat of here.
It is by means of gold that we solder either two pieces of gold,
or two pieces of platina, or, in fine, a piece of gold and another
of platina. In the first and third cases, that is to say, when we
solder two pieces of gold, or one of gold and another of platina,
the gold employed for soldering should be of the inferior
standard to that of the pieces we wish to unite. Thus, if this
latter is 20 carats, we should use an alloy composed of three
parts of IS carat gold, two parts of fine silver and one of red
copper ; we melt the whole in a crucible, roll the solder which
results from this melting, as thin as paper, and preserve it for
use in the form of particles from two to three, and even four
millimetres in size, which we designate in the workshop under
the name of papillas.
But, ordinarily, we solder together two pieces of platina,
with fine 24 carat gold. We can, however, employ for this
purpose, and it is that we make, of gold at 22, and even at 18
carats fine; but the pieces soldered together with this latter
are not so intimately united. It must, however, be known
that the solder is as much more solid as the platina upon which
we pour it has been more strongly heated. Some dentists em-
ploy for this solder green gold, of which we have already
spoken, which is merely an alloy of gold and of silver, a metal
more consistent than each of its component parts, which we
may sometimes render, and without danger, a little firmer by
adding to it a very small quantity of copper.
Let that be as it may, we solder the gold and platina by
means of a lamp and blow-pipe. An oil lamp having a large wick,
is generally preferable to an alcohol one, because it gives a
larger flame and more heat; as to the pipe, it is a tube of cop-
per or iron, of a cyhndrical form, diminishing in size from
that of its extremity which is to be received in the mouth
into the one from whence the air escapes, and where it forms
a rounded angle. Notice the different times of the operation.
The pieces to solder being perfectly cleaned by a light file, we
unite them either by a thread of iron, or by a little diluted
plaster; we place, then, by means of a brush covered with a
432 OPERATIVE MEDICINE AND PROSTHESIS,
solution of borax, or with a small pair of pinchers, the pieces
of solder upon the proper place, that is to say, upon the line
where the two pieces touch, if they are juxta-placed, or upon
the superior piece, if they are super-placed ; then we slightly
heat the whole, without which the borax, which is in a liquid
state, might abandon the water in which it is held in solution,
and the solder would be disarranged.
If we wish to solder near a point which has been already
soldered, we cover the soldered point either with an iron wire
or mixture of whitening; the first method is particularly ap-
plicable to objects which we wish to envelope circularly; the
second to pieces with plain surfaces ; in every case, the flame
should be directed particularly to the spot upon the solder
which we wish, exclusively, to fuse. If we desire, for exam-
ple, to solder the teeth upon a plate, the teeth being fixed upon
this base by means of plaster, as we say, we put the piece upon
a small burning chafing dish, we increase the fire so that the
piece may be properly heated, whilst the plaster and borax may
be dried ; being assured that the solder is in the right place, we
use the pipe for carrying the whole flame upon this point ;
under its increasing action, the solder melts and flows upon
the parts we wish to be united. We shall treat this subject
more particularly when we come to the application of solder-
ing to each object.
The operation terminated, we leave the piece to cool ; then
we pickle in order to remove all the asperities which might
render its surface unequal ; then we boil it in a second very
light water; this we call precipitating, and which is done in
a platina receptacle. If now we should wish to give to the
piece a red color which would approach nearer to that of the
gums than the yellow gold ; and the crotchets, the ligatures,
the plates themselves, and in general to all the parts visible to
the sight, we should wrap with an iron thread that which
we wish to color, and plunge the piece in the same liquid in
ebulition. But we can only obtain this red color, a true oxy-
dation, by dipping it many times ; if we pass the degree wish-
ed, it becomes a blackish red. This color once obtained,
should we;polish the piece, and even burnish it as some au-
OR MECHANICAL DENTISTRY. 433
thors advise ?* No ; for, in polishing it too much we prevent
it from adhering to the parts, and, in giving it brilhancy, we
render it more apparent.
The preceding is a summary knowledge, which the dentist
should possess, of those metals which he most habitually em-
ploys ; we might here advise him to keep mercury away
from these metals which he might have need of in the con-
struction of the dorcet metal or any thing else ; for, by its
contact, it renders them brittle by the great tendency it has to
amalgamate with them.
Manner of taking Imp?^essio7is, of making Moulds, of Adjust-
ing and Stamping Plates or Bases of the different pieces
of Artificial Dentures.'\
When the arts of imitation were still in their infancy, den-
tists were content, in the construction of pieces of artificial
dentures, to take only summary dimensions of these pieces,
and to work them in the presence of their patient, from whom
they required long and laborious sittings. But, in proportion
as the arts progressed, means are expected of us which permit
at the same time a more perfect imitation of nature and the
greatest possible economy of time. We proceed then to take
exact impressions even from the mouths of persons, to procure
moulds from these impressions, and to use these latter in the
construction of the work.
We do not know precisely to what author is due this happy
invention, which opened an easier way for dental prosthesis,
by conducting right to the end, and by drawing to us persons
who removed the uncertainties and doubts of the ancient pro-
* "If, in spite of all we have done to render the metal very brilliant, it
is not sufficiently so, it must be burnished with care," (Audibran's work
quoted, page 181.)
t We shall only treat here of metallic bases, upon which the attention
should be most particularly fixed, as being the most used ; the construc-
tion of hippopotamus bases having been noticed whilst treating of that
substance, and those of mineral paste in a summary manner at the same
time.
434 OPERATIVE MEDICINE AND PROSTHESIS,
ceedings. This is very certain, that neither Fauchard, '*nor
even Bourdet, whose work was of 1756, made nnention of it;
they speak only of taking measures for commencing pieces,
which they complete as they themselves say, only by trying
them in the mouth.
The first work in which it is spoken of, is the report that
the medical society published in 17S9, upon the incorruptible
teeth of Chemant, and in which it is said that this practitioner
took moulds loithwax, upon which he poured plaster, and thus
obtained exact models. However, Laforgue, in the first edition
of his treatise, which appeared twelve or thirteen years later
(IS02) adopted still the ancient method ; but, in 1805, Gariot
recommended taking impressions, and in 1808, Dubois Fou-
cou gave a description not less clear than minute; then, as
soon as the following year, Maggiola spoke of it as of a defi-
nite conquest acquired to the art, and placed it in the number
of its improvements that were the least equivocal ; and in his
second edition, which appeared in 1810, Laforgue adopted it,
notwithstanding his antipathy for innovations which were not
made by him. All the authors which have written since, have
recommended this method with reason, as an excellent one,
for which nothing better has been used; we have also des-
cribed it, with all the proper details, and particularly one man-
ner clearer, which has not been done until the present day.
Of Impressions or Moulds in Wax.
Until the present, wax has been employed for taking impres-
sions. Most ordinarily, it is virgin wax ; some dentists, how-
ever, employ yellow, such as we find in commerce, whilst
some authors prefer that which is colored in rouge with the
addition of a little turpentine. These diflferent kinds of wax
having appeared too soft and too easy to be deformed, Maury
has proposed to make some composed of two parts of white
wax, one of white lead, and one-half of grease, the whole
colored with cochineal ; but, the odor which the grease
always takes in heating, would always prevent this composi-
OR MECHANICAL DENTISTRY.
435
tion from becoming generally used, cleanliness being an im-
portant matter in every thing ; if, on the other hand, the white
of lead, which probably is the carbonate of lead, or lohite lead,
had not poisonous properties which should interdict the use
of it; we, therefore, give the preference to virgin wax.
We advise the use of wax after two methods ; in the first
case, after having softened it before the fire, or preferably in
warm water, and having removed the humidity from it by
pressing it in a linen cloth, in order to soften it anew in the
hollow of the hand, finally, by rendering it perfectly homoge-
neous and free from every fissure, and all lumps, we make a
roll of it of the thickness of the thumb, which we feature and
to which we give primitively the form of the part of the dental
arch that we wish to imitate, by having the precaution to hold
it thicker in the places where there are spaces, and particular-
ly to fill the alveolar vacuums ; then we make the teeth and
toothless parts penetrate this mass by raising it so far that the
gums may be enclosed ; we press it inwardly and outwardly
with the fingers. We then free this mould by removing it
with the greatest precaution in the same direction with the
axis of the teeth ; then, when it becomes firm, we wipe out
with a badger-brush the saliva or blood which it might con-
tain ; we remove, with every precaution, every thing which
appears useless, as much inwardly as outwardly, and at the
extremities. ^
In the other method, we place the wax in a box, a kind of
semi-elliptical gutter of tin or silver, upon the anterior part of
which is a shaft which forms a handle. The walls of this
receptacle, ofiering some resistance, oppose the deformation of
the wax. We apply it upon the place which we wish to imi-
tate, by placing it in such a manner upon this that there will
be left an impression of the neighboring teeth upon each side ;
then we remove the apparel by following with care the direc-
tion of the teeth; we then plunge it in cold water, and remove
with a deUcate cutting instrument all the superfluous parts
which are about the circumference. This method of proceed-
ing is far from having the advantages whidh authors generally
suppose ; it is in the first place painful for the patient, because
436
OPERATIVE MEDICINE AND PROSTHESIS,
it requires a greater pressure than the method which is exe-
cuted by means of the fingers which permits strength, more or
less great, to be apphed, according to the sensibility of the
parts, and by smaller portions at once ; finally, it always gives
too large impressions, for we cannot press against the walls,
as we can with the fingers. We never use it, and advise
it to be abandoned.
The teeth to be replaced not being always upon the same
side, we should, in certain cases, in order to obtain more pre-
cision, take separately, with different pieces of wax, the im-
pression of each breach, cut these pieces as if they were des-
tined to imitate the teeth, and preserve them, in order to cor-
rect, at a later period, the model. We might find great diffi-
culty in taking the impression of a part of the converging
teeth by acting, as we shall show, in a vertical direction, be-
cause that part of the wax which should touch the gum, being
larger than the separation which remains between the teeth
towards their free edge, could not pass it without deforming
itself In this case we take the impression, not from abox^e
downwardly, or from below upwardly, but from front back-
wards and from backwards front, with two pieces of separate
wax, forming a mould, in two places, similar to two valves.
Most authors think, that in the generality of cases, the sim-
ple model, that is to say, the single impression of the defective
place, suffices to establish the precise indications. It is, how-
ever, as often necessary to have models which indicate the re-
lations of the teeth of the two jaws, or even of those between
them. In order to accomplish this, we would advise a double
impression to be taken, by letting into a mass of wax ;
using, however, the necessary precautions to make the jaws
close in the precise way they are accustomed to ; the move-
ment of the jaws should be carefully noticed, to see if the im-
pression is exact. But very often the occlusion of the mouth
is such as to destroy the intermediate ridge which should sep-
arate the jaws, and then we have only a representation of the
anterior face of the superior and of the posterior face of the in-
ferior ; thus, this method is only applicable to cases where the
jaws have between them a great interval, or strike the one
OR MECHANICAL DENTISTRY. 437
upon the other. We think it is much better to take the model
separately; the habitual dentist would always establish the
natural relations by presenting the moulds the one upon the
other, having had care to take for an indication some mark.
Now, how shall we proceed to take an impression of a jaw
in which no teeth are left, whilst in the other it wants none,
or only a few ? We, at first, take an exact one of the existing
denture, and preserve it for a model ; we, afterwards, take an
impression of the toothless part, cut the wax, which repre-
sents this part, to the presumed height of the absent teeth,
the mouth being closed, and adjust the mould with the
irregularities of the cutting edge of the existing teeth, in such
a manner that it touches equally every where.
Finally, as the places destined to receive the artificial teeth
are not always so well arranged that we are not obliged to ex-
tract some bad teeth, or some portions of teeth, we should, as
far as possible, perform this preliminary operation before taking
the impressions. If, nevertheless, the person should not wish
to be deprived either of this tooth, or of that root, at the time
when we are ready to provide for their replacement (that
which would always be less advantageous than to wait for
cicatrization,) we might be obliged to take the impression such
as it is, that is to say, by proceeding as if the object wjiich
should be removed did not remain there, either by cutting this
object upon the model in order to adjust the piece, or even by
leaving for it a necessary space in the mould, and by fiUing
this space when we extract the tooth.
Of Models or Moulds in Relief.
By confining ourselves to the work that we shall now de-
scribe, we might' have a good representation, in moulds, of the
parts of replacement for which we would provide ; but we
might not be sufficiently advanced for this, because we would
have before the eyes and under the hands nothing of that
which is necessary for the construction and adjustment of the
pieces ; it would be necessary to make a mould in relief for this
impression : we employ for this, plaster or sulphur.
For either the one or the other of these substances, we com-
54
438 OPERATIVE MEDICINE AND PROSTHESIS,
mence by enveloping the impression in a bandage of glazed
mastic, of potter's earth, or simply of a paper covered over
with paste, so strong, that is to say, so thick that the liquid
substance with which we would fill the impression would not
break it ; about two or three inches in height, the two ends
of which, in fine, should be maintained by an iron thread.
This preliminary precaution being taken, and the impression
well cleaned, even covered with a Httle oil for the sulphur, we
place the pieces of iron thread in the cavities which corres-
pond to the long and separate teeth, in order to sustain or
mend them if they have need.
As it regards plaster, we use white, sifted fine, such as figu-
rists use; we dilute it slowly by pouring water into it, until it
becomes of the right thickness ; once diluted, and before it ac-
quires a certain consistency, we pour it lightly by shaking the
impression in different directions in order to drive out the air
which might have glided between the two bodies, we finish
filling it by pushing the plaster with a stylet in order to thicken
it, and make it penetrate into all the anfractuosities. When
we employ it, we dispense with enveloping the wax impres-
sions with any bandages ; we contented ourselves with hold-
ing this latter in our hands for receiving the plaster, and as the
mould obtained might not have a base sufficiently thick, we
apply it upon a quantity of diluted plaster, to which it adheres,
and which we conveniently cut off before it is altogether dry.
As it regards the sulphur, for which the bandage is useless, we
melt a sufficient quantity of it, and when it is about to con-
geal, we pour it by layers, and by frequently renewing it we
make it extend over all the parts.
Whatever may be the substance employed, when it is hard,
we gently present the whole to the fire in order to soften the
wax, and to detach it the more readily; then we remove, with
a cutting instrument, all the inequalities or superfluities of sub-
stance which might cause an error in the construction of the
piece. Some persons say, they are content to make moulds
of wax ; but it is evident that its softness would render it alto-
gether improper for the purpose for which it was designed,
which is to adjust upon it metallic plates. It would not serve
OR MECHANICAL DENTISTRY. 439
as a rectifying model, that is to say, one destined to be pre-
served in order to be used as an indication in the frequent
cases where the mould, which had been employed to make the
impression, might have received some alteration.
Of those substances, which we are about to describe, plas-
ter is most generally employed ; it requires, however, to be used
while fresh, because, if it is too old, it will not congeal. Some
practitioners, in order to give it more hardness, have advised
diluting it with Flander's paste, which joiners make use of,
(glue ;) this mixture, which is nothing more than plaster of
paris, would be excellent, for it acquires the consistency of
stone ; but it has the disadvantage of requiring a long time in
preparing and of hardening slowly. We often aid the desic-
cation of plaster by the addition of a little brown free stone.
Finally, if the sulphur has the advantage of a certain hard-
ness, it has this great inconvenience that, prepared in the lab-
oratory, it spreads around a very inconvenient and disagreeable
I'apor. The joining together in their perfectly exact relation
of the two moulds, by means of a wheel, with teeth, estab-
lished in their posterior part by a projecting edge in the one,
and a practical cavity in the other, constitutes that which we
call a?i articulated mould, indispensable for large pieces. The
form of the projections is round or triangular, so also the cavity
destined to receive them. Some dentists make but one between
the two extremities of the branches represented by the alveolar
arch ; others by establishing one directly behind each of its
two extremities.
One thing which is still very important to know, although
few authors speak of it, is, that whatever may be the material
employed for making a mould, the diminutions of the impres-
sion obtained always exceeds a little the object which we wish
to represent, because the latter becomes slightly swollen, which
the wax does not sufficiently reduce. The result of this is,
that the teeth which form the two sides of the semi-circle are
thicker than the natural ones, the space which separates them
is necessarily a little straighter, and the piece intended for the
place would fit loosely. \i is then that it becomes necessary
to take impressions in relief, which we have advised to be
440 OPERATIVE MEDICINE AND PROSTHESIS,
taken, separately, for each place where artificial teeth are re-
quired; in placing them upon the mould, we shall see how
we shall have to file the latter.
Finally ; let us terminate that which relates to impressions
and to moulds in relief, which they serve to give, by saying
that wax employed for this purpose should be new. We
should, therefore, melt it in a pan containing boiling water, in
order to remove from it all foreign substances ; the plaster
which adheres to it is precipitated by its weight, the other
foreign matters float upon the surface, and may be skimmed
oif. The mass of wax thus purified and cooled is renewed,
and by being poured into saucers previously oiled, is made
into cakes most convenient for use.
The Construction of Plates or Cuvettes and Stampmg them.
Moulds made with plaster and sulphur, obtained with the
precautions we have given, furnish an exact representation of
the place that the piece should occupy which we propose to
make : this we use for the adjustment of the plates or cuvettes
upon which the teeth are to be mounted. This adjustment
is made in two ways. First, when they are thin and very
large, we partially adapt them to the metallic mould with pin-
cers, aided, sometimes, with the burnisher; we name this in
the goldsmith's shop amboutir ; when thin plates have a cer-
tain extent, are strong, and, particularly, when they should
make a part of a dentier, or complete piece, they must be
stamped^ that is to say, they must be placed between two
moulds, which, receiving them reciprocally, impress upon
them the desired form.
In both methods we commence by making a kind of model
of plate with a thin leaf of lead, but possessing sufficient re-
sistance to prevent it from becoming too easily deformed ;
we place it upon the mould, and give it the form the true plate
should possess. Then, if we only wish to incorporate the leaf
which should form this latter, it being sufficiently annealed,
in order to have more malleability or suppleness, is cut upon its
pattern, then applied upon the mould of plaster or sulphur, of
OR MECHANICAL DENTISTRY. 441
which we take the principal dimensions, with which, in a
word, we harmonize it as well as possible, by the aid of pin-
cers, until it covers and encaps it exactly; by managing the
holes and projections, or filing these latter, which should be
enclosed until they are wedged in.
In order to give, more readily, to the plates the projections
and depressions they might offer, we have constructed, long
since, pincers of different sizes, some of which have one of
their ends rounded, in order to be received into the other,
which is concave, in the manner of an instrument in a case,
of whrch one has a protuberance which is received into a cavity
in the opposite side.
If, on the contrary, we wish a true stamp, we are obliged to
substitute for the plaster or sulphur mould, which suffices for
the first operation, a mould sufficiently resisting to support the
effort of a pressure great enough to stamp the plate. In order
to do this we make one of lead, to which we ordinarily add
about a sixth of antimony, in composition,* in copper and
even in iron, in melting.
For the manner of using the lead composition, we, how-
ever, proceed : We place in a wooden box, a quantity of pot-
ter's earth, rendered moist, and with which some practitioners
place a little sifted sand; we plunge the sulphur or plaster
mould carefully in it, sprinkled with a little of the powder of
Ucopade, in order to prevent it from adhering to it, and, as this
immersion when forced might not give an exact impression, we
press the potter's earth up against each side of the mould; we
then remove it with great care, so as not to injure the matrix.
The lead or composition is next melted in an iron ladle, then
it is removed from the fire, and when it has partially cooled,
we pour it into the matrix, having, previously, used the pre-
caution to sprinkle it with the powder before mentioned.
When it is entirely cold we remove it by means of a hook or
* Bv composition, we mean two substances, one of which is known
under the name of Darcet, and of which we have given the formula ; the
other is that of type-metal, which is composed of eighty parts of lead
twenty of antimony, and a very small-quantity of copper.
54*
442 OPERATIVE MEDICINE AND PROSTHESIS,
file, we next rectify it, that is to say, we correct the metallic
mould by comparing it to the isolated reliefs which serve then
as rectifyers, as we have said.
As it regards the copper mould which we were the first to
employ, its construction requires a practice which few dentists
possess ; we advise this part to be entrusted to brass founders.
These moulds are rarely, however, obtained as perfectly as
those of lead : they are always to be corrected by the primitive
model. Once obtained, we wash it in water to free it from
foreign bodies that might adhere to it; we then rub it with
soft wood sprinkled with potter's clay.
Although the mould may be in lead, in tin, in composition,
or in casting of copper or iron, lead is nearly always preferred
for the counter-mould; for it presents the least resistance. In
order to obtain this, we place in a wooden box a little fine
sand, upon which we place, flat-sided, the mould previously
rubbed with a mixture of chalk and water, we then surround
it with a ring of pasteboard or sheet iron, about four or five
lines from it, but sufficiently secure to retain the lead if it
should flow over the mould ; we pour this metal on to the
thickness of about an inch, and when the whole is cold, we
separate the two pieces by means of the hammer. We some-
times make the counter-mould by pouring the melted lead in
a box of potter's earth twice as large as the mould, and we
drive this latter in before obtaining the exact impression. But
this method can only be employed for moulds whose teeth do
not present too great limits or too wide spaces, for then we
could not separate them from each other; we would be obliged,
in this case, to cut the teeth ofi" nearly at the base.
This counter mould once obtained, as in the most simple
case, that is in cases where we could adjust them without per-
cussion, cut upon the provisional plate which has served for the
pattern, we place it between the mould and counter-mould,
we strike upon this latter, regular and moderate blows with
the hammer, and, when we are very certain that the plate has
not moved from its position, we put the whole together upon
the piece of square steel, that we have named an anvil^ and
by means of a punch or steel, or more directly, we strike upon
OR MECHANICAL DENTISTRY. 443
the counter-mould with a heavy hammer, which acts in the
manner of a balance. We remove the plate, cut from it that
which we judge to be superfluity of periphery, smooth it with
a file, restore the depressions that is necessary for the contour
to contain, which the pressure might have changed, and it is
very certain that it will adapt itself to the piaster mould for
which it has been disposed ; if it had any particular imperfec-
tions, it would be better remedied then.
Some practitioners, to be certain that all points of the plate
touch the parts to which it is applied, warm it and apply to its
inner surface a thin layer of wax, then put it in the mouth ;
the projecting parts, pressing the wax, mark the points which
require to be more deeply impressed. This increased precau-
tion may have its advantages, since it conduces to greater pre-
cision, but in ordinary cases it can very well be dispensed
with, and be resorted to only for pieces of larger dimensions,
where an exact co-adaptation is indispensable.
The result of this is, that nothing is more variable than the
form of plates or metallic cuvettes. Aside from the common
character which they necessarily have, as all the other bases,
by presenting them as a whole under the form of a gutter des-
tined to receive and cap the alveolar border, we seldom find
two which exactly resemble each other ; this is explained by
the diversity of surfaces with which they have to be antago-
nised and harmonised. Some are intended to rest upon a sur-
face perfectly continuous and deprived of teeth : others are
interrupted, and pierced with holes or simple slopes for teeth
still remaining. These holes or slopes never present an open
angle ; we usually furnish their circumference with small flat
rings, in order to diminish and even to annul the injurious
effects which might be produced upon the teeth by the con-
tact of a cutting surface. Finally, the cuvettes are some-
times formed of two pieces by a prolongation passing behind
the remaining teeth which they support. This prolongation
is either a continuation of the plate itself, or a band attached
and soldered ; the first is altogether preferable, because, with
an equal force and size, it avoids the projection of the solder-
ing, and harmonises better with the part which should sup-
port the piece.
444 OPERATIVE MEDICINE AND PROSTHESIS,
These different methods which we have described of rais-
ing full moulds and using them for stamping the plates, which
at a later period serve as a support for the teeth, are those
which have been described by authors up to the present, and fol-
lowed by most practitioners ; but, whatever some may say and
others think of them, we have rarely found in the plaster model
poured in the first wax mould, the precision necessary in
every circumstance. Nearly always in taking a second im-
pression from this mould, in sheet lead, or in any other sub-
stance, we have had the trouble of making upon the parts it
was intended to cover a plate which would be stamped like it.
This inconvenience suggested to us the idea, when a
piece of great extent is required, particularly in the develop-
ment of a piece in which is contained the anterior portion of
the alveolar arch, has suggested the idea, we say, of never
stamping the true plate in gold or platina without having first
made one of sheet lead sufficiently thin to enable us to adjust
it to the parts with our fingers, or by the aid of a burnisher or
pincers, and, however, sufficiently firm to be worked with-
out losing the form which it is necessary to give to it.j
When this provisionary plate is obtained, we try it as often
as it is necessary in the mouth, in order to adjust it, until it
fits with perfect accuracy, and we then use it for the procure-
ment of another plaster model, by means of which we obtain
the true plate, which should be an infallible guide.
Many persons to whom we have described this method of
procedure, the only one, according to our opinion, for obtain-
ing plates, cuvettes or bases of perfect accuracy, have objected
to it, for the reason, that it not only increases the amount of
labor, but that the similitude of the successive objects, taken
the one from the other, diminish of necessity as they approach
the last, the second mould would be less exact than the first.
To this, we reply, that the plate of lead becomes the first
mould, since it is not adapted to receive the true plate until
we have ascertained that it is perfectly correct.
Certainly, this second plate would become useless if the
first was taken with a substance so resisting that it would ex-
perience in its general relations, particularly in its anterior
OR MECHANICAL DENTISTRY. 445
curvature or in the plan upon which each of its angles should
bear no marked changes. The wax has not this advantage ;
it preserves and in the detail certain linear impressions which
are not reproduced upon the lead plate, and with more reason
upon the one of gold or platina, which should be afterwards
stamped ; but the linear impressions are altogether insigniiS-
cant to us ; that which is important is the persistence of the
form impressed in the mass, the exactness of the whole, con-
sequently the coadaptation of the piece.
This method of taking primitively a stamp in lead has still
two other advantages ; the first, is of tracing exacdy the height
that the second plate should have in front, by tracing in a care-
ful manner as much within as without the surface, which
should rest upon the gums, and the time when it should stop;
the second is economy of material. We cannot then recom-
mend it too highly to practitioners desirous of obtaining cor-
rect cuvettes.
However, whatever may be the method chosen for obtain-
ing the cuvettes, that which we cannot repeat too often, and
which should always serve as a rule for procedure in their
construction, is this, that resting upon the gums, they should
form a base capable of modifying the pressure the artificial
pieces always exert. As to their size, it should be calculated
according to the disposition of the place and extent of the
toothless alveolar circle. Then, should a plate rest upon the
solid roots ? It suffices that it should cover the roots of the
teeth. If there are no roots, on the contrary, it should have a
certain size and form a kind of gutter capable of embracing the
the alveolar border, and even of advancing a little beyond it;
this eases the teeth around which the crotchets of the piece
are fixed, the piece being then supported by the alveolar bor-
der alone, and not upon the teeth.
Let us add that the plates should be so large in every direc-
tion that we may make the proper slopes for maintaining the
posterior part of the teeth in place. And as the notched places
become necessarily straighter, and consequently weaker, we
avoid the liability of their bending or breaking by soldering
to them a piece of gold wire capable of augmenting in thick-
446 OPERATIVE MEDICINE AND PROSTHESIS,
ness the part which has been increased in length, or what
we prefer is to solder to it another plate. This wire may be
bent in form of a crotchet (clasp) to embrace the part of the
tooth behind which it is placed. It sometimes happens, in
this case, that we make a separate plate for each toothless
place, and reunite these separate plates by soldering them sol-
idly to a circular piece, made of strong gold or platina wire,
rounded upon the side corresponding to the tongue. But it
is easy to see, that this method, is inferior to the preceding
one ; we never adopt it.
If, in a series of anterior teeth, there exists one which devi-
ates so much as scarcely to be seen, it should, in certain cases,
be covered by an artificial tooth. This may be done by con-
structing a guttered plate, pierced with a hole through which
the natural deviating tooth should pass ; a small vertical edge
to which the artificial tooth may be soldered, will furnish a
support for it. In the same manner a tardily developed tooth
may be covered ; and against the extraction of which, we
should be particularly guarded, more especially so, when only
a small part of its enamelled crown can be seen. But as in
its development which occurs sooner or later, although at un-
certain periods, it might raise the plate, and cause it to lose
its perpendicular position, it is necessary to pierce the latter, so
that no obstacle shall ^oppose its growth or force it to take an
improper direction. We have met with many cases in which
practitioners, for having disdained this precaution, or ignorant
of the nature which induced us to notice the necessity of it,
have seen pieces deranged very soon in the construction of
which a great deal of skill had been displayed.
Different Methods of Mounting Pieces of Artificial Dentures,
that is to say, of uniting Teeth to their Supports or Bases.*
No pieces of artificial denture, such at least, as belongs to
•See in our introduction, in which we have treated in two separate
paragraphs, of the mounting of teeth upon their supports, and of fixing the
piece in the mouth.
OR MECHANICAL DENTISTRY.
447
the substance which we have said was almost exclusively em-
ployed, is placed in the mouth without the assistance of another
substance, which serves as a support or base. These supports
are pivots, metallic plates, of which we shall now treat, or of
bases made of hippopotamus, or any other osseous substances,
or even of mineral paste.*
In the infancy of the art, practitioners were content for the
retention of a series of artificial teeth united, to string together
like beads. "It was only necessary then," says Fauchard,
"to pierce each tooth with one or two holes, the one larger
than the other, according to the size of the teeth. These holes
should be made from one of the lateral parts to the other, in
such a manner, that they will correspond to each other, and
that the teeth should have the same level that the natural organs
had. We pass through these holes two threads of gold or
silver, of medium thickness, which should successively be
passed through all the teeth ; we rivet them by the two ends,
then finish, by adjusting the roots of the teeth together if they
need it, so that they may be arranged equally upon the gum."
We might have some hesitation in believing that Fauchard
maintained it in place, for he advises the method not only for
pieces "of two, three or four teeth," but he furthermore adds,
what modern authors have forgot to mention, that, "when
human teeth are thus used in the piece surpassing the number
I have mentioned, (from four to six,) we should, besides that
which has been said, apply upon the interior surface of the as-
semblage, a layer of silver or gold. This layer should be
pierced opposite the base of each tooth, as near the gum as
possible. These holes give passage to rivets of gold or silver,
which serve to rivet them to the teeth which are also pre-
viously pierced.f
There is not, as we see, but a step between this method of
mounting teeth and some others of which we shall soon speak,
*The pieces in which the teeth and bone are of a single piece, are an
exception to this rule, since the tooth never inclines in a direct vertical
manner, that is to say, without interruption upon the alveolar border,
t Work quoted, volume ii, p. 220 and following.
448 OPERATIVE MEDICINE AND PROSTHESIS,
particularly those which consist of fixing them upon the fore-
part of a plate. This difficulty was so much more easily
overcome, that Fauchard, in order to vary his method of
mounting, made one of a single layer. To do this, he ar-
ranged them all together, "by lodging the layer in the thick-
ness of each tooth, by means of a slope, cut upon the poste-
rior side of their base, and by fastening this layer to each tooth
by means of two small rivets, the one below the other;" this
is very nearly the method which Delabarre attributes to
Helles. But we will return to the consideration of mounting
teeth by commencing with the^most simple method, namely,
pivoting.
Pivoi Mountings.
The implantation of a pivot in a tooth, is one of the most
common operations of dental prosthesis, but is not, however,
one of the least importance, because the solidity of the piece
depends, in a great measure, upon it. We implant one or
more pivots in a tooth for two reasons ; either to fix it directly
upon a root, or to mount it upon some base. A tooth mounted
for the first of these two reasons, constitutes that, which we
commonly call a piyoHoo^A, audits dispositions demand more
ease, than we might believe at first sight, for the root of the
tooth in which it is to be implanted, requires minute and often
difficult preparation.
We shall notice first, in what consists the preparation of
this root, not in its relations with the part of the pivot which
it should receive, and which, in correct language, forms the
tenon, the pivot being the part implanted in the tooth, but in
its relations with the base of this latter ; we shall hereafter
speak of the fixing of a pivot in an artificial tooth. We shall
treat of the methods of effecting the implantation when we
come to the different procedures, in virtue of which, the arti-
ficial pieces are fixed, and maintained permanently, in the
places they should occupy.
Whatever may be the cause of the destruction of a tooth,
whether it be exterior violence, or the destructive action of
OR MECHANICAL DENTISTRY.
449
caries, it is very rare that it is destroyed to the level of the
gum ; there nearly always remains some portions of it, which
pass the alveolar border, and remain in the place they occu-
pied before they were lost. When these inequalities are con-
siderable, we can easily remove them with a file ; but it is
well known, that this instrument acts too slowly when it is
necessary to remove a considerable portion, sometimes a third
or fourth of a tooth ; in this case, cutting pincers, or a small
saw which acts from right to left, in the direction of the
gum, except for levelling and smoothing the whole, which
should be done with a fine file, conforming to the directions we
have given on the resection of the teeth.
Human Teeth Mounted upon a Pivot.
When the implacement is well prepared, that is to say.
when the root is filed in such a manner as to present a slight-
ly concave surface, so that the gum may slightly cover it, we
then prepare the tooth to be placed there, after having taken, if
we think it necessary, an impression of the place of replace-
ment, a precaution which many practitioners dispense with, and
and we are of this number, notwithstanding it is recommended
by some as the best way of arriving at the most favorable result.
We know that a human tooth often harmonises better with
those between which it should be placed ; sometimes, how-
ever, a mineral tooth, but rarely a hippopotamus. Admit that
it may be a natural tooth, (an incisor for example.) we select
a healthy one of the same class, of the same side, of the same
color, not, as it is commonly said, of that which it shall re-
place, but of those on each side of it, for the tooth to be re-
placed, may, from the cause which has occasioned its loss,
have taken a different color from the adjoining teeth ; it might
be generally replaced with a similar one, it would be better
assuredly to match the adjoining teeth, however, in order to
destroy every suspicion of its being an artificial tooth, the
patient might wish one presenting the appearance of the lost
tooth, he being accustomed to it. We cut it below the level
of its neck, in order to try it in the empty space to see if it is
450 OPERATIVE AIEDICINE AND PROSTHESIS,
of the right length and breadth. We then place it perpendicu-
larly upon the root, the surface of which having been previ-
ously made red, for the purpose of leaving an impression
upon it.*
As it regards the place for introducing a pivot for uniting
the tooth to the root, it may be ascertained by placing a light
layer of wax upon the former, and pressing it upon the latter,
which will leave a light mark indicating the proper point, using
the precaution to wet the wax so that none of it shall remain
in the root; when this is neglected, repeated failures are gen-
erally the result. For a contrary reason the base of the artifi-
cial tooth should be dry when the wax is placed on it.
The method of placing a pivot in a tooth destined for the
replacement of another, has perhaps occupied the attention of
dentists too much. There is no author who has written upon
the mechanical part of our art, and no practitioner of the pre-
sent day, so inexperienced in the profession, who has not hon-
estly proposed some method which he believes to be superior
to all others. All these methods to the eyes of the dentist,
who attaches only a reasonable importance to the details
of mechanism, are reduced to two principal orders, according
as the pivot does or does not pass through the whole tooth.
In the first case, the superior extremity of the pivot is rivetted.
to the posterior surface of that part of the tooth which joins
its cutting edge ; in the second case, it is forced or screwed
into it.
In either case, the tooth should be previously pierced in a
proper direction with a drill smaller than the pivot. If the
pivot should afterwards break through, the enamel should be
cut away with a grindstone over the termination of the hole
made by the drill. If the canal of the tooth is very large, it
should be filled with a peg of hippopotamus driven in with a
hammer ; in the contrary case, however, we enlarge it with a
* It is for this reason, (in endeavoring to imitate the lost tooth,) that we
have often, in order to gratify the wish of some of our patients,
placed for teeth of a bad color, eroded, decayed and plugged teeth.
From thence the necessity of having all qualities of them, as we have
previously advised.
OR MECHANICAL DENTISTRY.
451
broach, directed towards the posterior face of the tooth, because
if we approach too near the anterior surface, the presence of
the pivot might impart to the enamel an obscure tint. When
the hole is made in the tooth, we enlarge it, particularly at its
base, and straighten it with an equaliser.
Should we wish the pivot to go through the tooth, we
sharpen a piece of gold or platina, larger than the hole in the
tooth, and of the desired length, by diminishing the metal
which should penetrate it. The entrance having been ef-
fected, the pivot should protrude about half a hne, the part on
the opposite side of the tooth should be taken in a vice, and
the protruding part be beat down to the tooth, using the precau-
tion not to let the hammer strike the tooth as it would be lia-
ble to injure it.
Sometimes this pivot, instead of being in a single piece, is
composed, in the part which enters the tooth, of two pieces,
juxta-placed, and perfectly united together. Then we do not
rivet it, but separate the two ends which pass through the
tooth in order to lay them upon their side. We are careful,
however, before we do this, to form with a file or scraper, a
groove in the enamel for them to lie in, in order to adapt them
perfecdy. But this is not a good method for every case.
If the pivot is not to pass through the tooth which has the
advantage of not sacrificing the enamel of the superior and in-
terior part of the tooth, we make it in the form of a cone,
square or screw ; the tooth is apt to move and become de-
ranged when the first is is used, and it is often necessary to
use a transverse peg in order to retain it ; the form of the sec-
ond gives greater stability to a tooth ; but the screw pivot
holds a tooth more securely thaa any other, particularly if the
thread of the screw is sufficiently sharp to cut the osseous tis-
sue of the tooth, and far enough from each other. This latter
pivot has also this advantage, it permits of cutting away the
lower part of the tooth when it interferes with the occlusion of
the teeth.
As the six anterior teeth of the upper jaw are more frequent-
ly replaced with artificial teeth mounted on pivots, and as
their replacement is most important, we have taken these for
452 OPERATIVE MEDICINE AND PROSTHESIS,
an example, but there is nothing to prevent the appUcation of
teeth in this way, to the roots of the bicuspides. In the lat-
ter case, each tooth should have two pivots corresponding to
the canals in the roots of these teeth, which should be proper-
ly prepared for their reception ; if but one pivot is used it
should be placed between the two roots, over the inter-alveo-
lar partition, for if it be placed in one of the roots, it will not
give sufficient stability to the tooth.
We should not conclude our remarks upon mounting hu-
man teeth upon pivots, without observing, that if gold and
platina are the two substances most frequently employed for
pivots, we, nevertheless, meet with pivots made of bone, and
even of wood, which some dentists still use.
Mitieral Teeth Mounted upoti Pivots.
In treating of all that relates to the fabrication and disposi-
tion of mineral teeth, we have described the manner of intro-
ducing into their posterior face the crampings, to be united to
the pivots, and in virtue of which they may be properly placed
and solidly maintained. This union is effected by soldering.
That which we employ for uniting two pieces of platina,
and which we shall use in the cases of which we are now about
to treat, is gold of variable standards; some use from 14 to IS
carat gold; others from 20 to 22; these latter are, perhaps,
right, because gold of 18, and still more at 14, fuses at a much
lower temperature than that of 20 or 22, and spreads upon the
platina before the latter heats sufficiently to dilate. We have
already spoken of this in speaking of solders in general.
Whatever may be said of it, in order to provide a mineral
tooth with a pivot, it should not be previously cut, because if
it is, the soldering will be liable to break it, we proceed in
two manners : we fill the groove of the tooth with a piece of
platina, intended to level its posterior face, and upon which
we solder the pivot by a second fire, or we rather place the
pivot there afterwards. The first method, infinitely prefer-
able, is particularly applicable to plate teeth, whose pivots
would incline too much to the anterior to fall upon the middle
OR MECHANICAL DENTISTRY. 453
part of the root which should receive it; our method of arrang-
ing the cramps in mineral paste, dispenses completely with
the platina, as we perceive, these cramps, at first, fill the groove
and are even with it. The second method is, consequently,
more appropriate for pivot teeth.
In the second case, after having filed with care, as we have
said, the two pieces which we wish to solder, we cover them,
with a small brush, with a solution of borax, but only upon the
place where we wish the solder to take effect, we adjust them
properly and cover them with a number of small pieces of sol-
der, then we place the tooth either upon a piece of charcoal
about the size of a playing card, wrapped with fine wire to pre-
vent it from breaking, upon which the tooth is fastened with
cramps of iron wire ; or upon a piece of pumice stone, whose nu-
merous inequalities permits the tooth and pivot to be easily ad-
justed in the reciprocal relations they should sustain to each
other ; or, in fine, upon a piece of iron wire, which has the same
advantages as the pumice stone, besides of heating so readily
that the anterior face of the tooth may be made of the same
temperature as the posterior.
Thus prepared, we direct upon the solder, by means of a
blow-pipe, the flame of a lamp, which should be thrown on it
lightly at first, because, if we heat it too briskly, it will be
liable to crack the tooth, and it should be kept constantly on
the point where we wish the solder to take efl'ect, for the rea-
son that if it is too much diffused or thrown on a wrong point,
it will cause the solder to spread over too great a surface, or to
flow in a wrong place and aflect the solidity of the tooth. In
soldering the pivot, the solder is apt to flow upon the part
which is to be introduced in the root ; to prevent which,
it should be previously covered with a paste of Spanish white.
It is by the same means that we protect the anterior face of
the tooth which is liable to be attached to substance in contact
with it, and to be condensed by the heat. If, however, after
the operation, the tooth is dirty, or smoked, we can restore its
primitive color by passing it through an ordinary fire, and,
afterwards, soaking in warm water.
When a mineral tooth, intended to be placed upon pivots, is
55*
454 OPERATIVE MEDICINE AND PBOSTHESIS,
previously mounted upon this pivot, introduced, afterwards, in
its groove, or, rather, upon a small stem intended to be sol-
dered to it, it often happens, when it is not a talon, this pivot
falls upon the anterior part of the root, which should receive
it. We then make a slight opening into which for it to be
placed. In order to this, the pivot should be curved in the
form of a bayonet, before soldering it, or, rather, when it is
soldered, we saw into it about two-thirds of its thickness,
upon its anterior or external face in order to bend it, and saw
it in a similar manner upon its internal face, for the purpose of
bending it in a vertical direction. When we have done this,
we melt two small pieces of solder on the partially divided
angles for the purpose of uniting and strengthening them.
When we wish to mount a tooth upon a gold pivot, the
method of procedure is precisely the same, except that the
solder must be of an inferior quality, else in forcing it, the
gold would also be melted.
After uniting pivots to teeth, we diminish the length of the
roots upon which they are placed, we then complete their pre-
paration for the reception of the pivots.
Mounting Teeth upon Plates or Metallic Bases.
Whenever a pivot tooth is used, there must always be a root
upon which it may be placed, but although these may be fre-
quently found for the anterior teeth, they are, nevertheless,
often wanting. In this case we are compelled to have recourse
to other means for the retention of artificial teeth, which are
plates or metallic cuvettes.
The mannerof preparing these have already been described,
we shall now notice the manner of attaching teeth to them.
Human Teeth Mounted upon Plate.
The plate being prepared, we proceed to fit and adjust the
teeth to it, after having attached the fixtures to it which are to
retain it in the mouth, namely, crotchets, (clasps.) But as it
rarely happens that the mould has been preserved perfect, we
OR MECHANICAL DENTISTRY. 455
take from the plate, put in place a new wax impression, not
only of the toothless places which it should cover, but still of
the parts which surround it, so that the adjustment of the
teeth shall be made in all their definite relations. When we
have this impression, we fix the plate in the place where we
may wish to have it, fill the impression with plaster or sul-
phur, and obtain a new mould in relief, upon which the plate
rests for the adjustment of the teeth ; we cut these of the
proper length with a saw or file, but rarely with the latter, we
then cover the plate with a little rouge, applying each tooth
upon it to mark each point to be removed with the file and
engraver ; we make the median line the starting point, placing
the central incisores first by giving them the proper direction.
As to mounting the teeth, there are several methods of pro-
cedure in doing it; fixing them by means of a central pivot ;
by maintaining them with two lateral pegs, but placed verti-
cally, as the pivot of which there is but one variety; by ad-
justing with a screw upon the plate soldered to the cuvette, and
a peg behind; this gives them much strength, and permits
them to be advanced as may be desired. (We are now speak-
ing of human teeth, or teeth of the hippopotamus mounted
upon metallic plates.) If we employ one of the two methods,
we first place the pivot or the two pegs upon the plate, by
piercing the latter through and through, at the place which
we intend the tooth to occupy, or which corresponds to the
hole in it, which point may be indicated by moistening the
plate after having placed upon it a thin layer of wax, and then
adjusting the tooth, which leaves a mark or imprint at the
proper point; then we solder these pivots upon the convexity
of the plate, that is to say, to the side on which we apply the
tooth; and when they are solidly fixed, we place the teeth
upon them, and rivet them.
Finally, if the pivot is a transverse one, we rivet on the pos-
terior surface of the tooth ; if not transverse, we turn with a
little wire, and make it enter by the force of co-adaptation in
the tooth. But experience proves that transverse pivots, cross-
ing and rivetted on one side or the other are the best, because
they do not wear the holes, or allow the pieces to vacillate;
456 OPERATIVE MEDICINE AND PROSTHESIS,
the screw pivots which are so easily placed, and hold the teeth
so securely that it is difficult to remove them with pincers;
but we think they should be first introduced into the tooth,
and, afterwards, into the plate to which they should be rivetted.
Mineral Teeth Mounted upon Plate.
The method of mounting mineral teeth upon plate differs,
necessarily, from that of mounting animal teeth. We cannot
use those which have been previously carved and baked, we
are always obliged to carve them for the occasion. The plate
adjusted properly in the mouth, we take a second impression,
as before described, so as to secure the proper relative relations
between them and the plate, and which have been altered ;
we adapt the teeth upon the plate, one by one, and retain
them there for the time being, by means of wax placed behind
them; then we place the piece upon a small plate of iron, and
pour upon its anterior part a mixture of plaster, which, be-
coming dry, maintains the teeth in the place they should oc-
cupy, and which permits the wax, after being warmed, to be
removed ; then we solder them to the plate. We, moreover,
give to them greater solidity by soldering to their posterior
surface small plates of platina. After having tried the piece
in the mouth of the patient, such corrections as may be ne-
cessary should be made, noticing if the mouth closes natu-
rally, &c.
Mounting upon plate is not confined to one or more teeth as
is the case with pivots. It may be resorted to for all kinds of
pieces, from one tooth to a complete denture, and serves for
continued as well as interrupted dentures. By the latter term,
we mean pieces between the teeth, of which intervals are left
for teeth, which may be remaining in the mouth; and this
kind is most frequently met with in practice, and has the
greatest variety of forms.
When the part of the alveolar border, upon which we wish
to place an artificial piece, has experienced a great loss of sub-
stance, we ofiener mount this piece upon a base of hippopota-
mus, which permits us to imitate, perfectly, the gums. But
OR MECHANICAL DENTISTRY. 457
the color which we give to this piece, as we shall soon see, is
not very durable; on the other hand, the pieces thus mounted
always have a certain weight. These two reasons have given
us the idea of imitating the gums on the bases having the
mineral teeth.
In order to accomplish this, the piece being properly
mounted, we take a sufficient quantity of the following com-
position given by Delabarre :
Porcelain paste, . . . | i.
White sand, . . . . 3 ss.
Any oxydes we wish, . . gr. 10.
We add a portion of mica, or calcined gypsum, to render the
paste very fusible, and we reduce it to a very fine powder.
We apply a proper quantity of this paste either to imitate
the gums or only to interdent their points ; finally, we try the
piece in order to correct the defects which may now be found
to exist, then we put it to the fire. The presence of the gyp-
sum in the paste renders it fusible at a much lower tempera-
ture than would be necessary to fuse the mineral or bake the
mineral teeth unconnected with it; this paste agglutinates and
solidifies the two parts of the piece ; but if this composition
has the form, it has not the color of the gums.
There are two means which can be employed for coloring
it ; one, composed and employed by Dubois-Chemant, consists
in giving to the paste, of which we are speaking, the tint of
the gums, by adding to it a certain quantity, for example, of
precipitated purple of Cassius, or any other oxyde which has
the same property; but, as we may with reason observe,
the gums thus colored, want that transparency which life
gives to all of the animal tissues. Fonzi, who first noticed
this defect, believed he might avoid it by using jeweller's en-
amel, colored in melting, or afterwards painted. Pieces thus
enamelled do not last long, and we have been obliged to aban-
don the use of them.
Those who employ this method, proceed thus: they cover
the paste or biscuit which forms the gum, with an enamel
composed of:
458 OPERATIVE MEDICINE AND PROSTHESIS,
Petunse, . . 2 drachms.
Oxyde of gold, . . 6 grains.
Kaoline, . . 6 grains.
They cover with the gums, including their apices, and then
put it to the fire, but as it often happens that, from too intense
heat, the vermihon color of the enamel turns pale, they take
the oxyde of gold and beat it very fine, and add an equal part
of turpentine and lavender. When the mixture is made, we
pour a (oAv drops of oil into it, which gives brilliancy to the
color; then we paint with a brush that part of the piece which
corresponds to the gum. We then place this piece well dried
in an oven, and when it has become red, and thoroughly
glazed, we take the muffle from the fire, and let it become
cold, before we draw the teeth from it, as it might crack them
if we expose them too suddenly to a lower temperature.
As this work is complicated, and as it is always difficult to
calculate perfectly the results, we prefer, with reason, in a
doubtful case, that is to say, before furnishing the front part of
the plate with a substance for imitating the gums, particularly
where there is a loss of the alveolar border, we prefer, we say,
to make a true inlaying of hippopotamus, cut for this purpose,
fixed to the plate by the same pivots or screw which unites
the teeth to the latter, colored by one of the methods which
we have given. We have even made this inlaying with
blonde coral, that is, plain rose, but this substance increases
the work without a sufficient compensation.
Mounting on Osseous Bases.
In our previous remarks upon the manner of making hippo-
potamus teelh, we have described the method of constructing
with the same piece, teeth and their bases. But very often
teeth are fixed separately upon them, and we ordinarily use
for this purpose, natural or mineral teeth.
When we wish to mount human teeth upon a base, the sea-
horse, or any other osseous substance, cut in this manner;
it having been well adjusted in the mouth, we place the
OR MECHANICAL DENTISTRY. 469
teeth below it and adjust them in their proper places, and main-
tain them there with a Utile wax for modelling ; then, with a
foret (drill) we perforate them with holes in their ends, in
which we hold them with small pegs for the time being, upon
this base. We then increase the size of the holes, and some-
times substitute for the pegs, central metallic pivots, or two
pegs, either laterally or one before the other with rivets in
both bases; sometimes, on the contrary, screws, either intro-
duced through the teeth, and rivetted upon them, or, but
more rarely, introduced and rivetted in the side of the teeth,
but not crossing their base.
It is nearly in the same manner that we mount upon bases
of this sort mineral teeth. We obtain the adjustment neces-
sary by fixing them to wax, then we afterwards remove them
with care. The impress marked by their form indicates the
precise place where the holes destined to receive their pivots,
should be pierced, and we rivet them upon the concave part
of the base, using the precaution to make a counter-sink for
the reception of the heads of the pivots to prevent wounding
the soft parts with which they would come in contact.
In order that the teeth may not crack in rivetting, we place
them alternately upon a piece of lead hollowed like a V, upon
all the points of which they bear exactly; when this precau-
tion is well taken, we can use the hammer, without endanger-
ing the piece. We admit here, that it acts with a pivot which
does not cross ; but in the contrary case, we apply the rivet
of the tooth (human tooth) having its pivot previously attached
upon a steel block maintained in a vice, then we rivet the
other extremity upon the concave part of the base by means
of another small steel anvil, whose point we hold upon the
part that we wish to rivet, and upon which we strike with
precaution.
The person who is rivetting, cannot hold the anvil, the
hammer and the piece, he is obliged to have an assistant who
shall hold this latter. W^e may, however, rivet directly alone
with a pointed hammer, being careful not to injure the base,
which is necessarily weaker in all the points where the teeth
are received, than in the surrounding parts.
460 OPERATIVE MEDICINE AND PROSTHESIS,
As the rivets made directly upon hippopotamus are never
as solid as upon a metallic substance, we sometimes cut upon
that part of the base which corresponds to the extremity of
each pivot a groove intended for the reception of a very small
band of platina, pierced with as many holes as there are pivots
and upon which all are united in a countersink. We may,
however, make the extremity of the pivot, a small target of
platina or gold, countersunk in the base, and upon which we
rivet equally with the surface, so that it may not project.
As these osseous bases are particularly appropriated to cir-
cumstances in which the alveolar border, having lost its thick-
ness, has need to be replaced, we are often under the neces-
sity of giving to that part of the base which surmounts the
teeth, before a rose tint, similar to the color of the gums ; but
we tint them before the teeth are rivetted, so that we may remove
the teeth which should not be colored. We employ different
methods for obtaining this coloration. Laforgue advises sim-
ply to steep the piece a quarter of an hour in alum-water, and
to put it in a decoction of cochineal ; to remove it when the
color is as required, but according to his own remarks, the
saliva soon destroys the color.
Other dentists, perceiving the insufficiency of this proce-
dure, place upon the parts which should be colored, a layer of
hydrochloric acid, covered with water ; then they place this
piece in common water, and, after having well dyed it, they
imitate the color of the gums by coloring it with a brush with
many layers of cosmetic, employed as paint, under the name
oivinaigre rouge demaille. This method is more sure than
the preceding ; the following one lasts equally as long. As
all bony tissues contain on oily matter which opposes their
impregnation by the coloring principle, at least until they
have undergone a preparation which deprives them of it, we
boil the piece in a lye of soda, in which we put a few drops of
oil. From this, a very hard soapy water results ; in a very
short time we take it out and wet with a sharp acid, as the
solution of tin with hydrochloric acid. Five or six minutes
after we put it in an earthen vase, placed upon the fire, and
containing 2\ drachms of madder, \ drachm of kermes, 7 grains
OR MECHANICAL DENTISTRY. 461
of crushed cochineal, and a pint of fountain water. We
boil it a quarter of an hour, agitating occasionally the liquid
with a piece of wood. The piece withdrawn, has ordinarily
a very deep color; we then plunge it in warm soapsuds, il
then assumes a rose color much more permanent than by any
method before described.*
Although pieces of denture whose bases and teeth are made
of a single piece of hippopotamus, are daily becoming less
common, a sufficient number are still made to render a des-
cription of the manner of coloring the bases, without atfecting
the teeth with the coloring matter, necessary. We first scour
the piece in a lye, of which we shall speak when we come to
speak of the manner of coloring the bases alone ; then we dry
it. We then steep the enamelled part of the piece several
times in a vessel filled with melted wax, in such a manner
that every part, which is not tinted, shall be covered. We
then remove with a file, or any other analogous instrument,
the parts which should be colored, being careful to free the
festooned parts of the gum between the interstices of the teeth.
We then rub the exposed parts in hydro-chlorate of tin, diluted
in water, before plunging the entire piece in the colored bath,
in a cold or lukewarm state, but not so warm as to melt the
wax from the teeth which it covers. This method of coloring
does not penetrate so deeply the parts to which it is applied
as to make it as lasting as the preceding methods.
Might not the property of madder, which is given as a nu-
triment to animals, by coloring their bones red, be profitably
employed by those who would wish to furnish pieces of bone
for making basis of medium size? This kind of coloration,
which is the result of a vital process, and not the effect of a
simple impregnation of thin layers, might evidently accom-
plish the double end we wish to obtain ; the experiment
might cease when we had reason to suppose that a sufficient
red tint had been imparted to the bones. However, this is
* Practitioners who employ this method, go so far as to say that bases
thus tinted, are more durable than those which are not. This supposi-
tion seems to us gratuitous^
56
462 OPERATIVE MEDICINE AND PROSTHESIS,
merely a suggestion which we make without attaching any
very great importance to it.
As to the method which Delabarre* advises of obtaining
the briUiancy of dentures composed of animal substances,
which are always much too white at first, a method which con-
sists of covering them with a brush, with an alcoholic solution
of resin (he does not say which) colored with a little cobalt of
azure, and which would be left to be destroyed by the saliva,
we cannot conceive, in truth, how a man so judicious, could
eve^ have had such an idea. What person could ever have
the patience to keep many days in his mouth a coating as
improper as it is offensive to the eye ? Is it not more simple
to make the piece undergo the preparation of which we have
spoken, before they are mounted, and of coloring their bones
as we shall show?
We should not omit to mention, in this place, that it is pre-
ferable to make the bases or mountings of hippopotamus of a
single piece, though we sometimes find it necessary to unite
two pieces of this substance by means of a bony peg, if the
work is a continued series, or, by means of a metallic cross
piece, if it is an interrupted ; this would be, by far, more solid.
The desire of giving much solidity to a denture of human
teeth led some ancient practitioners to implant them in the
base, that is to say, to sink into the hippopotamus, holes large
enough to receive the roots of the teeth rounded with a file.
Each tooth, thus forced in, is rendered still more solid by a
peg passed fi:om within outvirardly. This kind of mounting
has not the solidity which it seems to have at first glance,
because the base, weakened by the enormous holes made in
it, is liable to be broken, particularly at its anterior part which
is very thin ; for this reason, it is rarely employed at the pre-
sent day. It is on this account, that bases of hippopotamus
upon which gutters for the reception of the teeth are formed
are abandoned.
Finally, we make mountings of bone and metal. To ac-
complish this, we adjust a plate of platina or gold upon the
* Work quoted, volume 1, p. 280.
OR MECHANICAL DENTISTRY. 463
mould, to the vacancy we wish to fill, then rivet upon it a very
light piece of hippopotamus, fashioned in the form of the gums
and colored accordingly, and supporting such teeth as may be
required. Pieces constructed in this manner are light, and have
great strength, because, however slight may be the thickness
that we give to the false gums, the plate upon which they are
placed, sustains them perfectly, while it permits the different
means of attachment to be soldered to the metallic cuvette ;
but their adjustment should be perfect, else particles of alimen-
tary matter would collect and exhale an unpleasant odor.
Mounting upon Mineral Bases.
If, in writing this work we have had no other end in view,
than an exposition of our art, to the exclusion of everything
else, in forming principles, we abstain from speaking of min-
eral bases, because, however well the bases themselves may
be made, and with whatever care we may adjust the teeth,
they are destined to sustain, the construction of these pieces is
always difficult, and in every case difficult to maintain in the
mouth. However, as many authors, such as Audibran,Dela-
barre and Lefoulon, (the last writer,) in speaking of some de-
tails, we could not pass this subject in silence, in order to de-
monstrate such as have defects in their use, and are difficult
in their construction, and to turn young practitioners from
their use, or to regulate their use in some rare case, those, for
example, when we are called upon to supply dentures for
those who cannot bear the contact of metallic cuvettes, or
for whom we might have reason to fear the buccal fluids
would very soon destroy a base of hippopotamus.
But there are two things to be considered in these kinds of
pieces. The construction of the bases themselves and the
implantation of the teeth. That which relates to the former of
of these, might without doubt be better placed with the details
connected with the fabrication of mineral teeth. But as this
should be preceded by moulds of the parts for which it is
destined, we think it best to speak of it after having treated of
all which relates to this latter subject. In regard to these
bases, the opinion of practitioners, who still abstain from ad-
464 OPERATIVE MEDICINE AND PROSTHESIS,
vising the use of it, divide upon the question of knowing if it
is possible to make them wholly of mineral substances, or if it
is not better to make them in part of this latter, and in part of
a metallic substance.
The great shoal of the partisans of mineral bases of small
dimensions, as of complete bases, is in the shrinking of the
paste which prevents that accuracy which is desirable, and
which is comparative, compared particularly with that obtain-
ed from metallic or hippopotamus bases. We might in vain
take the precaution of making the paste larger, according to
some, a seventh, others an eighth and ninth, than it is to be,
or if definitely fixing its dimensions after it has become dry,
as Audibran advises ; the difficulty might be diminished, but
not obviated.
In every case should we be fortunate enough, either by ac-
cident or otherwise, these bases can never be employed ex-
cepting for a continued series, the holes which would be
obliged to be made in an interrupted series would give a fra-
gility to it, which would render their use objectionable. Du-
bois-Chemant, himself, was so struck with this fragility, that
he soon renounced these kind of pieces and preferred to make
as many isolated pieces, as he had vacancies to fill, except
when he held them united by means of a piece traversing the
internal part of the dental arch.
But admitting that we may first make these bases so just
that they will fall perpendicular upon the part which they
should cover ; secondly, give them lightness and besides a
desirable solidity, how shall we furnish them with their teeth ;
if we wish to fix mineral teeth in the paste before the paste
dries, they would abandon it always so much, that very pre-
judicial spaces would remain between them, and it would then
require that the paste should be made of a more tender sub-
stance than the tooth. If we are willing to make in the
paste, holes or implacements for teeth, we could never rivet
the pivots upon which they should be mounted, without
running the risk of breaking the piece.
Delabarre has thought he could avoid these different incon-
veniences in making his base, after the manner he had of
OR MECHANICAL DENTISTRY. 465
making the points of gums of which we have spoken, half of
a metallic, and half of a mineral substance. In order to do
this he mounted mineral teeth with pivots soldered upon a
plate; then he furnished the spaces which existed between
this and the teeth with a porcelain earth moistened, and sub-
mitted the piece to the action of fire. But, we repeat it, all the
attempts that we have made in this respect have convinced us
that it is extremely difficult, we might say impossible, to arrive
at such results that the relations in which the constituent parts
of these pieces have been placed are not destroyed by baking.
We conclude, then, that bases, and with greater reason, den-
tures of mineral paste, form pieces whose inconveniences are
so manifest that we should always prefer those that we have
previously described. Audibran, by recommending the con-
struction, always, of several of these pieces at once, in order
to be prepared for accidents which might follow, pronounces .
the most formal condemnation of them; and Lefoulon, in ad-
mitting that of six that we may construct at the same time,
we are not always sure that the fire will restore 07ie perfect
one, might as well have dispensed with the details that he has
devoted to their fabrication.
Of the Different Methods of Fixing and Maintaining in the
Mouthy Pieces of Artificial Denture.
Teeth mounted aher the directions that we shall lay down,
having occupied us thus far more with principles than de-
tails, will completely remedy the deformity resulting from
the loss of those they are intended to replace ; but dental
prosthesis has not only for its object to deceive the eye, but
also to subserve their functions. From thence the necessity
of maintaining the different pieces of artificial denture so sol-
idly fixed in the mouth that they may not follow all the
movements of the jaws, but still more, resist the power which
is habitually exerted upon the natural teeth, and, conse-
quently, assist in mastication.
These methods of retention vary according to the circum-
stances to which they apply, and differ much from each other.
56*
466 OPERATIVE MEDICINE AND PROSTHESIS,
By reducing them to their proper physical worth, we find that
they act in five principal manners ; first, by that which we call
gomphosis, or implantation as pivots; secondly, by co-adapta-
tion as cuvettes, simply, juxta-placed; thirdly, by compression,
as with crotchets ; fourthly, by attraction, as ligatures ;
fifthly, by reactio7i, as springs. Let us examine each separately.
PivotSj or Implanted Tenons.
We have seen, in treating of the methods of mounting arti-
ficial teeth, how we furnish them with pivots; it now re-
mains for us to show how the implantation of this pivot in
the rivet is eff"ected.
In most cases, the dental canal of the root is free, that is
to say, deprived of the central ganglion, and it is only neces-
sary to enlarge it in order for it to receive the pivot of the
tooth, which should always be sufficiently large to resist
without yielding the efforts of which it is the abutment.
This is not, however, always the case, we are, sometimes,
obhged to destroy this nervous organ, whose existence would
not permit the introduction in the canal of the root of any
body without occasioning the most acute pain ; we then have
recourse to one of the methods we have heretofore indicated, in
order to destroy the pain of which the teeth are so frequently
the seat.
Let us admit that the root is deprived of all sensibility, that
it is healthy and properly filed ; the first thing to be done is to
enlarge the dental canal, either with a small steel or simple
iron equaliser, which we lightly turn in the fingers, having
care to use it slowly, and to often moisten it in order to pre-
vent it from choking; or, better still, with a drill. As, in this
case, the root, not having been softened by decay, has pre-
served all its hardness, we will have need to attack it with
more force ; on this occasion we employ the drill that we have
already described, and which offers the necessary resistance.
In the case where the root is decayed, the equaliser is most
convenient; it should only be about one inch and a half in
length, be cut with three sides, pointed and, particularly if of
OR MECHANICAL DENTISTRY. 467
Steel, but slightly tempered, without this precaution it might
break by the slightest movement, and occasion much pain to
the patient.
The use of the drill requires some precautions; 1st, it is
not necessary, at first, to employ any force, for it should pene-
trate progressively into the canal ; 2ndly,\ve should be assured
that it follows the direction of this latter, and does not pierce
the root as far as its extremity. Understanding these princi-
ples, we commence by enlarging only the opening of the
dental canal by means of an equaliser; then, the head of the
patient being properly placed and maintained by the left arm
which surrounds it, we present with this hand, to the freed
orifice of the canal, the drill which we have had care to roll
upon the cord of the bow; then we fix it there by the aid of a
small metallic shank, (rose drill,) mounted upon a handle upon
one side, but provided at its other extremity with a cavity in-
tended to receive the rounded part of the stem of the drill ;
then, finally, with the right hand, we make the bow act, hav-
ing the precaution, as we have said, to remove it, from to time,
in order to moisten it. We enlarge this first hole with a larger
equahser, and when we judge that its size is sufficient, and
approaches the extremity of the root, we clean and completely
dry it with a little cotton in which we envelope a small me-
tallic probe.*
This being made, we try the depth of the hole in order to
know what length we should give to the pivot ; we cut this
latter, and we file it until it is of the size of the drill employed
for piercing the root. But what form is it necessary to give to
it, and how shall we fix it? Most practitioners, those, particu-
larly, who, with equal worth, prefer a simple to a complicated
method of procedure, are satisfied to give to the pivot a cylin-
drical rather than a pyramidal form, to make some small
notches in it for wrapping it with silk or thread, put the tooth
* It is necessary to know that it is not always right to direct the perfo-
rating' instrument in the direction of the dental canal ; for example, when
the incisores have many roots, and when we pass between them, or when
the root deviates from its ordinary direction.
468 OPERATIVE MEDICINE AND PROSTHESIS,
in place, to attest its solidity by slight lateral movements, and
to press strongly upon it with the fingers, or with plate nip-
pers, or, finally, wiih the aid of a small piece of wood, having
a small groove for the reception of the cutting edge of the tooth,
upon which we strike lightly.
We may, still better, consolidate this tooth by putting upon
the rivet of the pivot, when it is crossways, a small punch
upon which we strike lightly, but having care to apply it upon
the pivot itself, and not upon the tooth, which the slightest
shock, in this place, particularly, might break. Finally, we
accomplish the end very well, sometimes, by striking simply
upon the cutting edge of the tooth after having placed a slight
layer of linen or paper upon it.
But these methods of implanting a pivot in a root, have ap-
peared too simple for some practitioners, eager for innovations.
From thence, the seal pivot of Fauchard, the screw pivot of
Bourdet, the clacking tenon of Maggiolo, the suberique pivot,
furnished with cork by llicci, the tenon a antennes, the per-
forated tenon, &c. &c.
These different pivots or tenons may have advantages, un-
der certain circumstances, but we say, that generally, they are
not as good as the simple pivot. We do not make an excep-
tion in favor of tenons or screw pivots, because, if this is a
good method for fixing a pivot in the artificial tooth, it might
not be for the root; in effect, if it is possible to stop, when we
please, in screwing the pivot in a tooth, we have not the same
advantage in screwing it in a root; it is then very difficult, if
not to say impossible, to have it fall in such a manner that the
exterior face of the false tooth, shall harmonise with the circle
and the festoons of the gum.
We may even remark, that practitioners, who have advised
the use of screw pivots for attaching teeth to the roots have
not thought, or dreamed of the impossibility of joining the two
parts between which they have left no space, and that the
gum might again cover the tooth. It is necessary in order,
in using ihis kind of pivot, that the root should be filed square,
which should not be. We do not, certainly speak here of
teeth already mounted upon pivot; but we conceive, very
OR MECHANICAL DENTISTRY. 469
readily, that there might be a method of mounting a screw
tooth upon a root with a screw; a pivot might be primitively
screwed upon this latter, and the tooth so arranged, that it
might receive the extending part of the pivot, by pure im-
plantation, as persons daily do who wear pivot teeth, the holes
of which are enlarged, and which they themselves put in
place.
Feeling the importance of this observation, and wishing, in
the meantime, to profit by screw pivots, thinking they were
most advantageous, in regard to solidity, in roots, some prac-
titioners fixed with a screw, in the hole made in the root, a
gold cylinder, of course hollowed, and screw shaped in its en-
tire length, within and without ; then they place a screw cy-
linder in the artificial tooth, of a diameter equal to that in the
root. When the two tubes are arranged, they construct a
screw without a head, of a thickness proportioned to the di-
ameters of the cylinders, put the tooth in place, introduce, into
the cylinder which traverses it, the screw which they turn
in order to fix it in the root, and the tooth superplaced, upon
the root has a stability, which we seek in vain to obtain from
any other procedure.*
Certainly, if this method was as easy to execute as to de-
scribe, it would merit the preference of all others; but inde-
pendent of time and expense, which are small matters in
comparison to other difficulties which have to be overcome,
as the partisans of this method acknowledge, in order to
give to the cylinder of the tooth and to that of the root the
same direction and to place them exactly, vis-a-vis, the one tq
the other; then, in order that the part of the pivot which
should be received in the cylinder of the tooth should be suf-
ficiently easy, in order to enter the root in proportion as we
screw it into the root, and so exact that it might maintain the
tooth perfectly immovable. We think that if one tooth, prop-
erly placed in this manner, has the merit of overcoming a great
* Maury has wrongfully taken the credit of this to himself; Laforgue
(vol. ii, p. 63) describes it at length and gives the honor of it to Durner-
gue. Talma and Tompson.
470 OPERATIVE MEDICINE AND PROSTHESIS,
difficulty, it has not, in the end, sufficient advantages to com-
pensate for the unfavorable chances of success that it offers.
It is the same with the pivot called clacking, by Maggiolo,
which Delabarre recommends where the other pivots have
already, by their use, considerably enlarged the hole of the
root destined to receive them, but whose construction, cer-
tainly an ingenious one, has led some persons,* who have be-
lieved that the question of an artificial piece consists in the
facility with which it can be removed and replaced. In order
to form an exact idea of this kind of a fixture, we must exam-
ine the clasps of a lady's bracelet. It is a stem to which
another is attached, forming a spring, and furnished with a
projection intended to be received in a hollow-joint, the thick-
ness of the cylinder which is to fill the root.
When we perfectly understand the manner in which this
pivot is attached, we perceive that, independent of the incon-
venience the practitioner experiences, in requiring so much of
the root, it has still more, this, that if, at the moment when
we make it penetrate the cylinder of support, the two stems
which form it touch by the pressure that they exert, they
cease to make it at the moment when the projection of the spring
penetrates in the joint of the cylinder, because, in introducing
the spring, it is made to traverse a distance equal to the depth
of the hollow joint in the walls of the tube or cylinder con-
tained in the support. These two stems, of necessity, leave a
space between them, immediately at the point where the false
tooth and root meet, in which the buccal fluids and alimentary
particles lodge.
Then, if we have to select between this clacking pivot and
the antennes, which is merely a pivot cut lengthwise, into
two parts, making a catch upon the walls of the tube of the
root, we would prefer this latter. It has, first, this immense
advantage over the latter, that the orifice of the hole is com-
pletely filled by the pivot; it is, besides, of a less complicated
structure, and, consequently, is more certain in its results.
• The author of the word Tooth, in the Dietionnaire des Sciences Medi-
cales, (vol. viii, p. 390,) declares he knows persons who wear teelh thus
mounted, and praise them exceedingly.
OR MECHANICAL DENTISTRY. 471
As to the precaution that Delabarre takes of fastening the
pivot by a transverse peg, introduced between the gum and
the root by an opening made in this latter by means of a very-
delicate drill ; it is more specious than rational. In effect, one
of two things, either the root forms a projection, without the
alveolus is sufficiently large, in order to render the implanta-
tion of the peg profitable, but then the place where the false
tooth and its support would meet is visible; or the root is cut
so close that it cannot be perceived, but then the drill is ap-
plied too near the point of the root upon which the false tooth
should bear, so that the exterior wall of the hole, through
which the peg should pass, could not offer a sufficient thick-
ness. This method, as we easily perceive, might be applica-
ble only to wood pivots, or would offer great difficulties if they
were metallic.
It is not only upon the form of the pivot that practitioners
have devoted themselves, but still more upon its apparel.
Thus, for simple objects, as cotton, thread, hemp, or silk, of
which we have spoken, we have proposed to substitute ami-
anthus, the bark of birch, and different metalUc substances, as
lead, gold and platina reduced to leaves sufficiently thin to be
wrapped upon a pivot. These latter substances are often em-
ployed, because they do not putrify, and exhale an offensive
odor; but not being susceptible of sweUing by moisture, they
do not always perfectly adapt themselves.
Unfortunately, one is not always so happy as to have to
deal with healthy roots, or where the canal has not been too
deeply destroyed by decay. In this latter case, it is necessary,
after having carefully removed from the root, all the soft parts
which can be detached from it, not about the pivot, but to fur-
nish the cavity of the root, with two light pieces of soft wood,
cut in the form of a V, so thin that they may be rolled round
the pivot which the humidity causes to swell, and to place
this latter in such a manner that it enters with force. These
small wedges of wood, have another advantage of making the
tooth recede or advance according as we place them, before or
behind the pivot. We sometimes employ, in similar cases,
either a kind of sealing or cramping, made with the fusible
472 OPERATIVE MEDICINE AND PROSTHESIS,
metal of Darcet, with which we fill the cavity of the tooth, in
order to pkinge the pivot in, during its fusion, this is particu-
larly appreciable to mineral teeth, whose pivot we heat; or a
small funnel of plafina.
The care that we take to implant solidly pivot teeth, proves
that it is merely a prejudice of opinion that induces some to
remove the teeth, in order to clean them. When they are in-
timately united to the roots, so that we might in vain endeav-
or to pass a thread between them, no putrid matter could be
introduced there. Every derangment is then only favorable to
the wearing of the teeth, or rather of the root, of which the
pivot would always, each time that we remove it, drag with
it, however particular we may be, some particle of it.
It then necessarily results from it, that it is a false belief,
which would deprive us of the power of testing, by pivots, the
solidity of pieces attached by cuvettes or ligatures, of which
we shall soon treat, or sustains upon metallic bases, under
this pretext, that the need of cleansing the pieces, require that
they should be frequently removed; to do this, the pivots
must be loose. When a piece is well made, and particularly
well adjusted, it should be rarely removed. The advice that
some practitioners give, amongst others Saveau,* of often re-
moving them, even every day^ in order to clean them, is an
error which cannot be too strongly condemned.
We remark, then, that when pivots, employed as accessaries
to other methods of fixing pieces, for example, soldered to
parts of plates which rest upon the alveolar border, have to
support the efforts of these pieces, whose abutment they very
often become, we experience the greatest difficulty in estab-
lishing an exact relation between them and their holes of sup-
port, as in the case of an isolated tooth, it is always prudent
not to abuse the resource that offers here, and to manage the
holes in order to make them useful at a later period.
As to the method of fitting pivots to the internal or con-
cave part of plates, it is simple. We commence by pierc-
ing the roots ; then having heated the plate, we cover it with
• Nouvelle Hygiene de la Bouche, 7 vol. 18 c. 1843, p. 310.
OR MECHANICAL DENTISTRY.
AT.
wax, for the purpose of applying it on the place it should oc-
cupy in the mouth, and upon which we apply it to obtain a
relief mould, corresponding with each hole. This impression
taken, we remove the plate, perforate it at the 'places marked ;
then replace it in order to pass the pivot from the convex to the
concave surface of the plate, which has been previously adjust-
ed in the root ; but this pivot should fit tightly in the hole, so
that it may be removed with it, without altering the position
it had in the root. If the hole is too large, a light blow of the
hammer upon the plate, or upon the head of the pivot would
soon reduce the one or increase the thickness of the other and
establish the correct relationship between them. This end
attained, we solder on the convex part of the cuvette, that we
may file or saw off the superfluous part. It is not well to at-
tach many pivots at once, because in securing one, we may
derange the other. It is, therefore, better to adjust and sol-
der them successively.
In a piece of a continued series, of a certain extent, we can
place as many as six pivots upon the plate ; this will dispense
with any other means of attachment, and would be particular-
ly applicable in those cases, where, from the absence of lat-
eral teeth, crotchets cannot be used ; also, in cases where
the lower teeth strike the upper in such a manner as to pre-
clude the use of these latter attachments.
If the different means which we have described, have suc-
ceeded in maintaining false teeth for a long time, implanted
upon doubtful roots, it is no less, always, very imprudent to
place them on roots where decay has destroyed nearly the
whole of the dental canal. It is useless, as some have impru-
dently advised, to employ perforated pivots for the escape of
pus; it might be so suddenly arrested as to occasion very un-
pleaaant fluxions, and even of nervous affections which the
extraction of the tooth alone would not arrest. The cause
which induces the formation of pus should be combatted.
Many young practitioners, for want of attention, commit this
error, and thus induce those with whom pivot teeth would an-
swer a better purpose than any other, to forego their use.
Prudence and skill, however, does not always prevent these
57
474 01 ERATIVE MEDICINE AND PROSTHESIS,
a'jcidents, for they may often be occasioned by a pivot too
long, which may touch the remaining portion of the dental
nei-ve, which we may have neglected to destroy, or by its frac-
ture in the cavity of the tooth. In the first case, the whole of
the artificial tooth will have to be removed ; in the second, the
pivot will have to be extracted. It is, generally, easy to fill
the first indications; not so with the second, at least, not with-
out breaking the pivot in the cavity of the root. It must
then be removed, either by diminishing the pivot or by en-
larging the canal.
If it breaks ofi' high up in the root, what is to be done?
Should we attempt extraction, as some authors advise, loith
pliers fitted and hollowed len^thwise^ forming indented gut-
ters ? But then these pincers would have to be very small to
be introduced into the root, and, besides, the root would be
very much weakened near its upper extremity. It would be
better, perhaps, to pierce the root with a small drill in such a
way as to reach the upper part of the pivot, then, a steel
wire, bent at the end, might be introduced, and the pivot ex-
tracted; but this would, certainly, always be to the detriment
of the internal part of the root.
Miel has invented a very ingenious instrument for the ex-
traction of broken pivots and drills. It is a small trephan,
with a tube in the centre for the broken pivot, and whose
walls form two branches, and are susceptible of elongation
and contraction. Moved upon a handle, or perforator for roots,
it destroys every thing surrounding the pivot, and permits us
to seize it. The small steel tube, terminated by saw teeth,
forms a miniature drill, and the one to which Maury says he
had recourse in a case like those just described, are nothing
more than the trephan of Miel.
All of these methods, of which the two latter are not ap-
plicable to cases where the pivot cannot be implanted in a
right line, have the inconvenience common to hollowing the
root; thus, we prefer to make a screw pivot, and form at its
expense a new hole. In this way, either the pivot thus liber-
ated falls out and leaves the hole ready for the reception of a
new one, or it is hollowed in the direction of its length to re-
OR MECHANICAL DENTISTRY.
475
ceive another of less size. But we can conceive, how, during
this operation, it is necessary to be in the habit of using the
drill, and how, consequently, we should always have present to
the mind, those principles which we have established for its
use, and the forgetfulness of which might be very prejudicial.
Finally, we can place, successively by the side of each
other, six mineral teeth united together. In order to do this,
it is necessary that the pivot of each should enter with much
ease the dental canal which should receive it. When the
teeth are adjusted and fixed in the mouth, we take the im-
pression of the whole with wax, that they may all come out
and remain in it. If one or more of these teeth should not
come, it may, afterwards, be removed and placed in its proper
place. We then pour upon it a sufficient quantity of plaster
to maintain them solidly united, then leave it to harden. The
wax being removed, we fix a metallic band upon the posterior
face of the teeth ; we fasten it to them with iron wire, and
solder it upon the plaster model.
We shall not term.inate that which relates to pivot teeth
without speaking of those which are maintained with crotch-
ets or ligatures. When we employ crotchets for the purpose,
they are soldered to the plate upon which the tooth is neces-
sarily mounted. The ancient dentists arranged these crotch-
ets in such a manner that the central point of the quarter of
the circle which they form, corresponded to the middle of the
side of the plate to which they were united, enveloping the tooth
as much before as behind ; they called these tenons with grooves.
But for this kind of crotchet we have substituted others of which
we shall soon speak. Ligatures used with pivots form an ex-
piditious method of securing and giving great solidity to a
tooth ; but they have inconveniences which renders their use
very objectionable as we shall soon show.
Pieces held by Si?n/ple Co-adaptation.
It is among pieces maintained in the mouth by co-adapta-
tion, that we place those sustained by juxta-position, aided,
for the lower jaw, by their weight, and by points of contact
476 OPERATIVE MEDICINE Al^D PROSTHESIS,
with the neigboring parts, for those of the upper. It is easy
to see that such pieces which receive in practice, but improp-
erly, the name of simple pieces, since they may be very com-
phcated, or flying pieces, since they do not move, may be more
particularly applied only to the inferior jaw, because, having
no attachments upon the sides, and not being retained by any
mechanical means, they can be kept m place only in a way
which precludes any movement. Their mode of application
comes under the principle of co-adaptation, these pieces, ordi-
narily, have a large base, hollowed for the reception of the
alveolar border, upon which they are intended to be raised
very high, and which they immediately encase.
These pieces are frequently used in England; we may even
maintain them nearly as well in the upper as in the lower
jaw, in obtaining, by the extent of the cuvettes for the first,
that which we accomplish by their own weight for the sec-
ond. Experience has even proven that a single piece can be
maintained better than two; in this latter case, it is true, it
would be safer to employ springs. Gardette, an able dentist of
Philadelphia, says Laforgue, was one of these practitioners
who, in his time, succeeded the best in the kind of work of
which we are now speaking; but it is as well to observe, that
the pieces which he constructed required, in order to attain
the precision of adjustment that he gave to them, so much
time, that the price of them was, necessarily, very high. This
observation might be just at the time when Laforgue wrote;
but if at the present time we employ a few of these pieces, it
is not because they require too much time, but because those
which are maintained in the ordinary way, are not valued.
Let that be as it may, these pieces rest sometimes upon the
jaws entirely deprived of teeth ; the contact of the lips and
jaws which press upon their exterior border, slightly rounded,
in the form of a hood, greatly aid in maintaining them ; some-
times upon the jaws which still have some teeth; these latter,
then, serve to give them solidity, either because they lean upon
them on one of their sides, or because they are received in the
openings constructed for them in the base of the piece.
In the first case, that is to say, when we have to construct a
OR MECHANICAL DENTISTRY. 477
piece without any attachment upon the jaw, (the inferior, cer-
tainly,) entirely unfurnished, we should then, as we say, be-
sides the regularity with which its base receives the alveolar
border, depend equally upon its own weight. This base is
ordinarily a thick cuvette of platina, the anterior contour of
which we enamel with a color like the gums, before fixing
the teeth upon it. But bases of the sea-horse are greatly pre-
ferrable, because, by its nature, this substance unites itself more
intimately to the gums than metallic cuvettes. These are the
pieces which it would not be well to traverse with rivetted
pivots, at least those made of wood. In the second case, that
is when the jaw has some teeth still remaining, we arrange
them, so that an exact relation will exist between them and
the piece ; this can only be done by taking a model of the re-
lations with precision.
Does it necessarily follow because compelled to make these
pieces heavier than the ones which are maintained by direct
means of attachment, that they should have great bulk? No,
for this bulk would exert a pressure upon the jaw, which, if it
were not painful, would, nevertheless, insensibly affect the
alveolar border. We cannot then condemn too severely the
opinion of Delabarre, who thinks that we should give to these
pieces a base composed of a mass of platina encrusted loith the
graver. This work, would not only be difficult, but when
we know how much trouble we have, to make a correct base
of hippopotamus, which we are obliged to carve upon a relief
mould, we see what obstacles we have to overcome, in order
to thus employ a metal as hard as platina. The greatest in-
convenience, we repeat, would be in the pressure of the piece
upon the jaw. We then think that this work would be very
difficult to execute, we would advise it never to be under-
taken.
Of Crotchets.
The attachment of teeth in the mouth, or rather, of artifi-
cial pieces, offers, as we see, particularly in regard to solidity
an invaluable resource to dental prosthesis. Thus this
57*
478 OPERATIVE MEDICINE AND PROSTHESIS,
method of attachment, whose advantages, however, it is not
necessary to exaggerate, since they are often purchased by
great inconveniences, might be, in the generahty of cases,
preferable to all others, if we never lost but the crowns of
teeth; if the roots always held them solidly implanted in the
alveoli; if these roots were always preserved perfect; finally,
if we had always to place them upon a piece of small extent,
because the larger pieces, would send all of its shocks to its
extremities, which would necessarily render it less solid and
would cause it to act laterally.
These favorable circumstances are, unfortunately, as we
have already said, far from being met with as often as we
might desire; we are then frequently obliged to have recourse
to other methods.
Amongst these methods, the most useful, after pivots, are
crotchets. We designate under this name branches of platina,
or better of gold, round or half round ; but most ordinarily,
plates, whose bent extremities serve to fix to solid teeth, artifi-
cial pieces, to which they are soldered or rivetted. Their
mechanism is so simple, and their use so frequent at the pre-
sent day, that one is disposed to believe, that their invention
can be traced to the most remote period of dental surgery.
However, this is not so, for not only the writings of Fauchard
and Bourdet make no mention of it, but there is nothing said
of it in the works printed in the first years of this century;
we are then led to believe, that they are the inventions of den-
tists of our epoch.
Crotchets act entirely upon the principle of compression;
that is to say, they should bind the teeth upon which they are
placed, but in such a way, that they will not pull them in any
direction : without this precaution, acting by attraction, or in
the manner of ligatures, they would glide under the gums,
separate the tooth from them, loosen the supporting teeth, and
cause their loss. They should then unite themselves to these
teeth in such a manner, as to fit perfectly upon them, for if
they exerted any friction, they would of necessity, wear only
the teeth they surrounded, and, whatever their size, they
would change their supporting angles. From thence, the ne-
OR MECHANICAL DENTISTRY. 479
cessity of never fixing them, in regard to their length, with-
out being well assured that they fit exactly upon the teeth for
which they are intended.
We conceive, then, that their development should correspond
to the volume and position of the tooth, around which they
should be passed. If this tooth is a large molar, they should
necessarily be larger and greater, because this tooth is larger
than those in the front part of the mouth, and not being seen,
we should give them a development nearly equal to a complete
circle ; whilst, for the anterior teeth, we give, in order to render
them less apparent, the least possible extent ; but, it is always
necessary, that they should fall slightly upon the anterior part
of the supporting tooth. To say, in effect with Maury,* that
we are content to give them, oi^diuainlt/, a half circle, would
convey the idea that we were unable to explain their physical
manner of action.
In order to render that part of the crotchets which borders
the dental interstices less apparent in front, we should cut it
lightly in festoons, at the expense of those of its edges which
touch the gum, particularly in the superior jaw, where the
least elevation of the lip, would expose the neck of the tooth
in front.
But from this necessity of rendering the crotchets as slightly
apparent as possible, it no less results, that Maury erred, as we
have said, by asserting that we should, in a general manner,
give them the form of a half circle : Lefoulonf is still less cor-
rect in saying, that the form of the crotchets varies, necessarily,
according to the form and disposition of the gums themselves.
Their conformation should, before every thing, as we know,
and as the end for which they were employed indicates, be
dictated by the volume, configuration and position of the sup-
ports which they should embrace. In this matter, as in many
others, the useful should be valued in preference to the agree-
able ; but we should certainly always seek to reconcile them.
When, by the shrinking of the gums, a portion of the roots
of the supports is exposed, it often happens, that the crotchets
* Work quoted, p. 356. t Work quoted, p. 380.
480 OPEKATIVE MEDICINE AND PROSTHESIS,
in proportion to this shrinking, embraces a part smaller than
that for which it was primitively intended ; they are then
obliged to close very much upon themselves ; but if they are
not sufficiently elastic, they will not be straight enough for
this part. In this case, it would be necessary to tighten the
crotchets, or surround with a non-putrifying thread, that part
of the tooth upon which they are accidently placed, and to
furnish them, themselves, with the same covering. This varia-
tion does not destroy the great usefulness of this excel-
lent method of fixation ; they have particularly this great
advantage, that of permitting the pieces to which they are at-
tached to be removed and replaced at pleasure ; they can be
cleaned when we think useful, and thus prevent the accumu-
lation of alimentary particles, whose decomposition in the
mouth is always injurious.
The authors of the word Tooth, of the Dictionary of Prac-
tical Medical Studies,* have committed an error in pretending
that ive use teeth for crotchets, iohen no part of the roots remain
susceptible of being perforated, in order to serve for abase for
a pivot tooth. It suffices, to read that which we say of the
conditions in which pivots should be used, in order to be per-
fectly convinced to the contrary.
But if crotchets may be employed in many cases where the
roots exist, even in a good state, no artificial denture, what-
ever may be its form and the substance employed for its con-
struction, can be maintained by crotchets, only when natural
teeth, or portions of teeth exist, capable of giving a sufficient
support, and these agents apply as well to pieces themselves, as
to plates or bases, which serve as montuses.
For example, do we wish to fix crotchets to a base of hip-
popatamus ? the method is simple if we believe the most of
elementary authors. According to them, it would consist,
* The gentlemen it is true, know little of dental prosthesis, for a little
farther on, they say : We sometimes prefer to ivory which changes, metallic
plates. If by ivory they mean the true tooth of the elephant, they have
erred, for more than fifty years it was renounced ; if, on the contrary,
they wish to say the tooth of the sea-horse, they err still more, because
we do not sometimes, but most ordinarily, prefer metallic plates to it.
OR MECHANICAL DENTISTRY. 481
simply in making a screw at the extremity of a gold wire of
the thickness judged necessary from the force of the piece and
the nature of the support; they then implant this screw, flat-
ten the wire with a hammer, and give to it the proper form.
But those who know how difficult it is to give this form to the
crotchets, even by trying them many times upon the mould,
necessarily find this method defective. We first fix not one,
but two screw pegs in the hippopotamus, and, the crotchet
being properly formed, we then pierce two holes, in which we
inti'oduce the two pegs with their heads countersunk.
If the piece is mounted upon a metallic base, whatever
may be the nature of the teeth, which are only fixed there
afterwards (since the construction of a plate and its furnish-
ment with crotchets, are only, so to speak, the two periods ibr
the same operation,) we think best to solder the crotchets.
In order to do that, we unite them, temporarily, either by sur-
rounding them with an iron wire, or with plaster, which is
preferable, particularly when we have many solderings to make.
In this latter case, the plate and the crotchets being placed in
relation upon the plaster mould, we take from the softened
wax which we apply upon the whole, and remove with it the
plate and the crotchets which remain in the same relations;
then we pour some diluted plaster upon the concave face of the
plate, we leave it to cool, and then remove the wax with much
case, in order to expose the metal, so that its fusion shall not
injure the soldering preparation.
If the plate is gold or platina, we solder after the method
that we have hitherto given, having care that the crotchets are
always of eighteen carat gold, the only standard in which this
metal is capable of acquiring the necessary elasticity ; an elasti-
city which we particularly obtain by hammering them upon
the elongated prolongation of a small anvil.
But if the plate be of platina and the crotchet is of the same
also, we unite them with soldering twenty carats fine, but not
with the ordinary soldering which, not penetrating sufiiciently
the two metals, does not give to the whole a necessary solidity.
It is always better, at first, to solder the crotchets only in part,
so as to be able to adjust them with more facility, and to open
482 OPERATIVE MEDICINE AND PROSTHESIS,
or close them at pleasure. If we solder them wholly, we
might often he obliged to separate them from the plate.
Crotchets may accidentally break, and Delabarre thinks,
that in most cases, it is better then to rivet than to solder
them to plates ; that which, to his eyes might have the ad-
vantage of giving to them more elasticity, because he would
not be obliged to submit them to the fire in order to solder
them. He sometimes advises us, in order to accomplish this,
to make crotchets of wire sufficiently strong to admit holes
intended to receive the pegs ; sometimes, on the contrary, he
solders the crotchet to a small solid plate, which he rivets
upon the principal mouture. We are far from entertaining this
opinion, first, because the elasticity lost by the fire is easily
recovered by the percussion of the crotchet, even at the time
when it is mounted ; then because one or many rivets never
possess the solidity that soldering gives to it, and it would
always be very difficult to rivet the crotchets very thin. As ^
to the plate, by the interposition of which, he wishes to make
the rivettings, it should be double as he says, and, then it in-
creases very much the thickness of the cuvette, or if it is tliin^
it does not possess the necessary solidity.
We have only considered crotchets in their simple form, but
the intelligent dentist would vary tliis form, and appropriate it
to the multiplicity of different cases, which are constantly pre-
sented to his notice. It is thus that when the teeth which
form the two sides of the vacancy which the piece should fill
do not appear solid enough to resist the compression of the
crotchets, he gives to the branch which carries them a suffi-
cient length in order to permit it to extend behind many teeth,
until it reaches the one which he judges fit for a support, by
weakening the effects of its elasticity by successively soldering
the one to the other demi-clasps, and forming in the places of
their union, small spurs which, insinuating themselves in the
inter-dental spaces, prevent all shaking. It is to this kind of
crotchets that Maury* improperly gives the name of springs,
as we may see in the following phrase : "Springs differ from
* Work quoted, p. 356.
OR MECHANICAL DENTISTRY. 483
crotchets, first because they can only be made with sixteen
or eighteen carat gold, secondly because they are much longer
and are attached to teeth very distant from the artificial
piece."
If the teeth behind which these demi-clasps should pass
were loose, we might give them more height, so that they
would offer demi-circular cells intended for sustaining these
teeth; we might, even, in order to give more solidity to the
support that they would offer to them, pierce them with many
holes through which ligatures should pass which would join
before. This method is the natural tendency of the treat-
ment appropriate for loose teeth, which we have noticed under
a therapeutic and pathological view, in the first part of our
worlc
The disposition of crotchets in half-clasps, successively sol-
dered the one to the other, unites the advantages of the spring
or elastic compressor., properly called, to that of the crotchet
which is often only an inert compressor ; this kind of crotchet
is very commonly employed at the present day, because to the
advantage that we have mentioned, it joins still more one not
less important, that of hiding the method of attachment,
which it carries back as far as possible.
The crotchets being fixed to the piece which they are in-
tended to keep in place, of which they, from that time form a
part, and to which they should, we repeat it, be soldered be-
fore the application of the teeth, it acts by passing round those
which remain in the mouth, and which are intended to re-
ceive them. This part of the adjustment of a piece some-"
times offers difficulties. When these difficulties are met with,
the young practitioner is much more embarrassed, as authors
who have hitherto written upon our art have made no men-
tion of it.
But when teeth around which the crotchets should be fixed
leave at the extremity of their crowns a sufficient space be-
tween them and the neighboring tooth, nothing is easier than
to pass these crotchets, bent in the direction and in the degree
wished, around the tooth, by introducing them, vertically,
through the dental interstices. But if this space is too nar-
484 OPERATIVE MEDICINE AND PROSTHESIS,
row, we diminish the thickness of the crotchet either with the
file, or. which is preferable, the hammer, which preserves a
great portion of its force, provided, however, that we anneal it,
without which it would easily break. When any space exists
towards the crown, we have not, as upon the plaster mould,
the advantage of opening a way for the pressure ; we pass one
of the crotchets by presenting it by its extremity to the trian-
gular space left between all the teeth about their necks, but if
the piece is small, the extremity does not present itself in
the direction necessary for its introduction.
What is to be done in this case ? One of two things ; either
to open a passage by the file at the expense of one of the two
teeth between which we wish to penetrate, particularly if one
of them is decayed; we rectify the crotchets by effacing
their curvature, then introduce them both at the same time,
in order to bend them upon the teeth, once passed. But as
they possess such thickness sometimes, that they are not easy to
bend in that state, without employing a pressure which would
be painful, we have sought another method, and we believe we
have found it by mounting one of the crotchets upon a rivetted
pivot forming a hinge, absolutely as an ear-ring. By this
method, the piece is presented within the direction proper for
one of the crotchets, and, once in place, the other crotchet,
which is lowered behind, is directed in the space which it
should occupy, and developes itself upon the internal, and
slightly upon the anterior part of the tooth, where it is fixed
by a light pressure, exerted by means of a pair of nippers.
In order to prepare cases where the vacancy is extremely
narrow, we are often obliged to cut away a small portion of
the sides of the teeth, with a file, to make room for the thick-
ness of the crotchet, particularly when we employ mineral
teeth; this might be done upon natural teeth, but it would
evidently render them less durable, for we would be com-
pelled to remove a portion of the enamel.
Finally, if we have to envelope with a crotchet the two or
three last molares, which have no space between them, or are
not decayed, so as to require filing, we make that which we call
a crotchet with pliers. This crotchet is made differently from
OR MECHANICAL DENTISTRY.
485
those we ordinarily construct, we think proper to describe the
manner we make it. We form, as for an ordinary crotchet
upon the mould, a clasp surrounding the first large molar by
its three faces, that which corresponds to the vacancy, fronting
the tooth ; we then adjust upon the second large molar, two
other half-clasps which we solder to the extremities of the
first, and the same for the wisdom tooth, having care that the
extremities of the crotchets which belong upon the posterior
part of the tooth should embrace it exactly. We perceive that
this kind of crotchet is no other than the double of that which
we have said wound behind the teeth, in order to fix it to
one other elongated by that which embraces the sides of the
teeth.
Of Ligatures.
The ancients maintained artificial pieces in place by means
of ligatures ; but the moderns, struck with the disadvantage
that these agents possess by so easily breakmg, and not per-
mitting the rapid displacement and replacement of the piece,
have very much diminished the use of them, without remov-
ing them altogether. Thus we employ them at the present
day only when it is impossible or difficult to have recourse to
other methods of fixation.
Ligatures are, to speak properly, only cords or bands which
we procure from the vegetable, animal or mineral kingdom ;
from thence their ancient distinction into soft and stiff liga-
tures. The first are threads of hemp and linen, or the threads
of silk known under the names of twist of raw silk, Chinese
root, Florence hair; the second are wires of platina or fine
gold. They are vertical, lateral, or compressive, and are even
susceptible of combining with pivots and crotchets; but they
nearly always act by an oblique and even sometimes hori-
zontal effect ; those which act in a direction inclining per-
pendicularly have necessarily more force.
Most frequently, we can maintain an artificial piece by lig-
atures only by piercing the holes in such a manner that the
thread shall incline towards the gums. The position and
58
4*^G OPKR.VTIVE MEDICINE AND PROSTHESIS,
direction of these holes vary according to the kind of work
upon which we apply them ; but it is necessary, always, that
their lateral orifices are placed a little beyond the level of the
gums ; if too far out without, they would be visible ; if too far
within, they would loosen the teeth which they surround ;
thus, the model is rarely a fit guide to the determination of
the precise point; with a crayon or small burin that we should
mark it upon the piece fixed in the mouth itself. We will ex-
amine each in particular, in order to appreciate the real or com-
parative value.
1st. Hemp and linerij employed under the form of twist-
thread, such as we employ for ordinary sewing, are resisting ;
but, swelling very much by humidity, they may exert upon
the teeth a very great traction. Employed under the form of
a flat-thread, or small fillets, they are less subject to shorten
by the humidity, but are more readily affected by the saliva ;
they are not used by modern practitioners,* and we only find
upon pieces worn by persons who inhabit parts of the country
distant from large cities or residences of dentists, and who are
compelled, by necessity, to make use of them.
We have recently sought to use for ligatures, the filaments
that we extract from the leaves of many kinds of aloes, and
whose utility we have been able to test for a number of ob-
jects, since our conquest of Africa. We have many times
tried this vegetable linen, and acknowledge that, although, it
is sufficiently strong, it, nevertheless, changes so readily, and,
consequently, merits no preference over the Ugature we shall
now treat of.
2nd. t^^ilk, ordinarily ,t can only be employed for ligatures,
after it has been arranged in thread. Thus twisted, it is
very solid, and its use is so frequent, because it changes much
less readily than the three preceding substances; but it has,
* Fauchard advises them, however, very often in preference to silk, of
which he does not know, it is true, our different methods of preparation.
See pp. 218 and 219, of vol. ii, of his work.
t Silk, every one knows, is an animal product furnished by the envelope
in which the silk worm shuts itself up in order to transform itself into a
chrysalis.
OR MECHANICAL DENTISTRY. 487
like them, the inconvenience of swelling by humidity, and
then, in shortening, of moulting, ascending easily towards the
gums, in order to reach the narrowest part of the teeth upon
which it is fixed, and thus wears them out as quickly, at the
same time that it pulls them in a different direction, and
loosens them. In order to give to the silk thread more solid-
ity, we impregnate it with a resinous gum, which not only
renders it less affected by the saliva, and thus prevents the
odor that its decomposition produces, but it also prevents its
shrinking so easily; it is this that we improperly call the
Chinese root, which we employ very firequently.
3rd. Florence hair is only a species of silk taken at the time
when the worm which produces it is ready to begin to spin,
and which we make undergo a preparation.* It also resmbles
small gut threads, softens and becomes flexible, hke them, in
warm water. Of all the soft ligatures we make more frequent
use of this for fixing pieces of artificial denture. The preference
that we give to it is owing, particularly, to its pearl and trans-
parent color, which renders it nearly imperceptible; it deterio-
rates very slowly,and warrants us, consequent freedom from the
unpleasant odor which the decomposition of other substances
produces; not unravelling, it does not relax; finally, being
nearly impermeable, it does not keep up about the neck of the
tooth stagnant humidity capable, in time, of decomposing
them. As humidity makes it elongate, we should preserve it
in water, or dip it in it a half an hour at least before employ-
ing it.
Whatever may be the substance which forms the soft liga-
tures, we confine them by knots which we form upon their
sides, and always, as much as possible, between and behind
* In order to obtain this thread, we select the largest and most trans-
parent silk worm amongst those which are ready to spin, and we plunge
them in strong white vinegar. We remove them after twenty-four
hours, and seek in its body for the gland, or sac, which contains the silk-
matter ; we draw this matter out, which is gelatinous, and we lengthen it
out from twelve to fourteen inches, with much care, so as to form a thread
as round and united as possible. This thread, notwithstanding its fine-
ness, is equal in strength to ten or twelve hairs.
4S8 OPERATIVE MEDICINE AND PROSTHESIS,
the teeth, so that they shall not be seen nor wound the lips.
In order to do this, we cross the thread twice in the same loop,
draw it moderately, and again cross it, but only once, and to
the reverse, in order to form a knot which we sometimes cover
with a third crossing. This being accomplished, we cut the
thread close with curved scissors.
4th. Metallic ligatures, whose use in our art, runs back very
far, seems at first much superior to all those of which we have
spoken, because they are effectively more solid, and because
they are easily applied ; but if they maintain perfectly artifi-
cial teeth in the first moments of their application, they relax;
rubbing them upon the necks of the teeth, wearing and ren-
dering them painful, and insensibly cut them. Let us add
to that, that they are more difficult to conceal, and we will be
forced to acknowledge that their advantages scarcely compen-
sate for their inconveniences.
We have seen, in speaking of metals, that gold and platina,
intended to make ligatures should be of the highest standard,
because in this state they preserve all the desirable mallea-
bility. In order to fasten these metallic ligatures, we employ
long, narrow and strong beaked nippers, with which we draw
out the posterior end, which we pass between the teeth, we then
turn it with the other thread towards the lateral parts, but ob-
serving that that which passes before the tooth should cross
under that which passes behind for the superior jaw, and un-
der for the inferior. This kind of ligature is not as good as
the flattened ligature which some employ, as the latter pro-
duce less friction. Some practitioners surround the tooth with
silk before they apply the metallic hgature. This precaution
counteracts only, in a very small degree, the inconvenience
which attends their use; they are little used at the present
day.
As to the methods advised by some ancient authors for
maintaining dentures suspended in the superior jaw, or simply
to the gums, by threads or crotchets passed through holes
made in either of these two parts, we judge it as barbarous as
ridiculous. We are astonished that an author like Delabarre,
should not fear to expose himself, by speaking of it, but re-
OR MECHANICAL DENTISTRY.
4S9
commended its application to the upper jaw, by declaring that,
whatever might be said of it, the operation has never caused
the least accident, because the perforation of the bone is not
painfuly as we are not liable to encounter large vessels, or im-
portant nervous branches, and the wound is less than that which
is occasioned by the extraction of a tooth*
Fauchard had, in the meantime, already expressed himself
in such plain terms, against the utility of teeth simply sus-
pended to the gums, as might prevent practitioners of his day
from employing it. He says,! "I had hoped, that the fre-
quent abuses which are practised daily might be corrected,
and that we might advise the discontinuance of piercing the
gums through, in order to make holes for suspending there an
osseous piece composed of many teeth, in order to replace the
incisores and canines of the superior jaw. The points which
fastened this osseous piece were bent like crotchets, piercing
the base of the two teeth in the middle of the artificial piece,
and running through the gums, suspended from these holes in
the manner of ear-rings; in such a manner that this was, so to
speak, a wearing piece, which obeyed not only the impulsions
of the tongue, but still more, that of the exhaling and inhaling
air. This piece pulled and troubled the gum. I have learned
from a lady, who experienced the inconveniences of this kind
of fixture, that a cough fortunately delivered her from a part
of this grievous fixture. It was necessary that this lady
must have a great desire to have her mouth furnished, in
order to undergo so cruel, and at the same time so ridiculous
an operation, without speaking of the dangerous conse-
quences that might result."
"I cannot even understand," adds Fauchard, "how a den-
tist could be so little jealous of his reputation, as to thus ex-
pose it, particularly at Paris, where so many able men of all
professions are found." This observation of Fauchard's is cer-
tainly still more applicable to our epoch than to that in which
he Uved, and where dental prosthesis was scarcely an art.
* Work quoted, volume ii, p. 41 1 .
t Work quoted, vol. ii, pp. 289 and 290, of 1786.
58*
490 OPERATIVE MEDICINE AND PROSTHESIS,
Those persons who might be seduced by the words of Del-
abarre, in favor of artificial pieces suspended by means of lig-
atures passed even through the thickness of the maxillary
bones, might, perhaps, object that the opinion of Fauchard is
not opposed to them, since he only speaks of pieces suspended
to the gums. To that we reply, that if, as no person can
doubt, the perforation of the bone is more dangerous, and
more painful than that of the gums, all that which Fauchard
says is infinitely more applicable to those which practise the
first operation than to those who confine themselves to the
second. If they still doubt the reprobation with which they will
be received by every physician of our day for similar opera-
tions, passing from the theory to the practice, we would ad-
dress to them these words, that one of the collaborators of the
Dictionary of the Medical Sciences* suggested, who wrote at
the same period Delabarre did, attempts being made at this
same time, by a dentist of Mayence, to practice these opera-
tions.
"This cruel operation appears to us, at least, useless, if it is
not dangerous. A good mechanical dentist has no need to
have recourse to it, and he must be greatly smitten with the
mania for innovating, or for singularizing himself, in order to
exhume for procedures which, as these, tend to carry the art
back to the ages of barbarism, where the surgery of the Arabs
knew only, were fire and caustic, and had, for example, no
other method of arresting hEemorrhages, than by cauterising
the wounds with burning oil." The inventors of similar
methods have evinced a great sterility of imagination; they
essentially depart from the medical philosophy of the present
age, whose object is to alleviate suffering humanity, by em-
ploying the most simple means."
To conclude, whatever may be the nature of ligatures em-
ployed as a method for maintaining pieces of artificial denture
in the mouth, they always have this inconvenience, that of
loosening the teeth around which they are attached. It is in
vain that we have been careful to choose those teeth which
* TouRNER, already quoted, vol. viii, pp. 30, 31.
OR MECHANICAL DENTISTRY. 491
are the most solid, and that we have diminished, by small
spans resting upon the horizontal surface of these supports,
the tendency which Hgatures all have of sinking under the
gums; all the efforts which are felt upon the piece are rapidly
transmitted to its extremities, and from thence to the places
where they are attached. Thus, it is necessary, when it is
possible, to spread the effect upon many points, and, in every
case, to avoid wearing ligatures.
Of Springs.
Independent of elastic agents which fasten artificial pieces
by acting by compression upon the teeth more or less near, we
even believe, in dental prosthesis, that springs, whose effects
are confined to a pure reaction, that is to say, which tend un-
ceasingly to maintain separated, one from the other, the two
pieces opposed to the one they hold, yield to the occlusion of
the mouth, in order to react at the moment of its opening, and
to follow, consequently, the principal movements of the jaws.
These springs apply, as we say, to double dentures, complete or
not, nearly always go in pairs, then fasten from each side to the
same places, in order to equilibrate regularly, and curve from
the depth of the mouth in order to accommodate itself to its
concavity.
In the infancy of our art, these springs were made of simple
layers of horn, of bone or of steel; but it was soon perceived
that the two first substances, susceptible of deteriorating by
the swelling that they experienced from the part of the humid
heat in the midst of which they performed their functions,
were not desirable, and that flat springs, of steel or any other
metal, had too limited a development to follow either the
lowering of the inferior jaw, or its lateral movements.
A kind of spring was then sought for, 1st, capable of im-
parting equal movements to those of a machine placed upon
the anterior portion of a lever, whose support is one of its ex-
tremities, whilst the other movable in different directions
exerts, particularly, a great depression ; 2d, of an easy use,
applicable to the plurality of cases, and neither being trouble-
492 OPERATIVE MEDICINE AND PROSTHESIS,
some to the tongue nor to the jaws ; Srdly, passing behind the
length of the denture, and applying in front in such a manner
as not to be perceived at the opening of the mouth.
From thence we have spiral ressorts, (or springs,) that is,
springs with cylindrical stems, and contorted upon its middle
part; those with double articulated plates, forming a reactor
fixed upon the side of the dentures, called grasshopper-legs ;
those with super placed plates in the manner of a carriage
spring, which Ave had employed before any author had given
a description of them: with undulated plate, with simple and
double scrolls.
Spiral Sprintrs.
Of these various springs, which may all have their own
merit, the most useful at the present time, the only one which
dentists the most desirous of succeeding use, is the spiral
spring, which, with the advantage of a reaction, easy to regu-
late at will, and distributed in all its length, can, consequently,
act also in a horizontal direction from below upwards, joined
to that of gliding easily upon the interior of the jaws by its
rounded surface.
Delabarre* is completely wrong, when he places the inven-
tion of these springs only at the period of Bourdet, who
speaks of them only in 1756,t and when Laforgue| pretends,
that in 1785 they were scarcely known ; they existed, and
were used, even before Fauchard,who expresses himself thus
in regard to them :|| "We now use in order to join together
the two dentures, with hinges and spritigs in the form of a
screw, or simply curved in a spiral manner."
If Laforgue had known this passage of Fauchard, he would
have been spared the trouble of denying that Lemaitre was
the inventor of spiral springs. To Lemaitre,^ a French den-
* Work quoted. t Work quoted.
J Work quoted, vol. ii, p. 140. || Work quoted, vol. ii, p. 282.
§This Lemaitre was, however, an intelligent dentist, for as early as
1784, he had presented (to the Society of Inventions and Discoveries,)
some perfect dentures upon v?bich a favorable report was made.
OR MECHANICAL DENTISTRY. 493
tist, who, in 1803, after returning from a voyage that he had
made to England, presented to the Lyceum of Paris a treatise
upon these springs which was accepted as a neio and proper
invention, for extending, say the reporters, the hmits of the art.
But if springs are of an ancient origin, they have, necessarily,
passed through many forms and undergone important im-
provements before arriving at the state of perfection which
has rendered their use so frequent. For instance ;* 1st. They
were first employed by fixing them either directly behind,
which might prevent the mouth from closing, if they occupied
more of the depth of this cavity than the place permitted,
which happened in nearly every instance ; or upon the sides
of the piece, but in an immovable manner, which would pre-
vent the inferior end from following entirely the jaw, and
would often force the piece to leave the alveolar border in
front; 2nd. It was for a long time believed to be sufficient to
give mobility to the insertion of the lower end, and the need
of diminishing their length which was opposed to the fixed-
ness of the piece was perceived and remedied by applying an
inflexible articulated lever upon the middle of one of the sides
of the inferior piece.
The invention of this method of terminating spiral springs
with levers articulating in the middle of each side of the den-
ture belongs to Maggiolo;t he had, doubtless, been conducted
by the idea that Ricci had had of reducing the length of the
spiral from three inches, which they had, primitively, to an
inch and a half, and to replace the flexible body which he had
replaced with a stifl" one.J This has prevailed over all au-
thors, because the result of it has been to hold the superior
piece'in equilibrium by forcing the posterior portion to form a
counterbalance which prevents it from exerting an effort upon
the front one.
Notwithstanding the slight modifications which this kind
* These reporters were Regnier, director of the Lyceum, and Donsire
Dubreuil, a physician ; both were strangers to the art of the dentist.
t Manual of the Art of the Dentist. Nancy, 1807. 1 vol. 12mo.
JLaforgue pretends, on page 143 of his work, that Ricci in construct-
ing them, had only imitated Masse, a skilful dentist of Versailles.
494 OPERATIVE MEDICINE AND PROSTHESIS,
of spring has undergone, we divide it, for its construction and
adjustment, into the body of the spring, which, is the spiral
properly called ; into the heads of the spring, which are the
levers by which this spiral is terminated, and into the parts
by which they are fixed to the piece.
Fabricatio?i of the Spiral Spring. — The body of the spring
is made with gold wire about eighteen carats fine, which we
turn upon a steel mandrel, perfectly pohshed, and of the di-
ameter of a large ^in. In order to do that, the wire having
been received by the wire plate the diameter that we judge
convenient to give to it, we pass it for the last time in the fire;
then we clean and polish it, the reduction of it having har-
dened it sufficiently to give it the necessary elasticity ; then, we
either employ a machine made expressly for, or make it in our
hand, in the form of rings more or less distant from each
other, according to the degree of elasticity that we wish to
give to the springs. Many manufacturers at Paris always
have them ready made, we generally procure them already
made from them.
Nevertheless, for the benefit of practitioners who, residing
far off from manufacturers, or for some other cause, are obliged
to make them themselves, we show how we proceed. We
take a piece of wood sufficiently tender, as the fir tree, and
flat, which we split ; we place the gold wire into its cleft, and
allow it to extend out an inch, and put the whole in a vice
which we screw perfectly tight ; we then take a pair of slid-
ing-tongs ; we introduce at the same time a mandrel between
its bits, and the end of the gold wire ; then by turning the
sliding-tongs with the right hand, we force the wire to ascend
through the cleft of the piece of wood upon which it straightens
itself in lengthening and rolling upon the mandrel, the left
hand sustaining it, and giving it the proper direction. The
rubbing that the gold experiences, by passing between the
two sides of the piece of wood, suffices to give it the neces-
sary elasticity.
Heads of the Springs. — Spiral springs once adopted as the
most sure and the most solid, and the necessity of terminat-
ing them with inflexible levers being acknowledged, we next
OR MECHANICAL DENTISTRY. 495
proceed to attach heads of the most convenient form for sus-
taining them, and facilitating their movements. It was at
first beUeved, that, inasmuch as the inferior jaw alone is mova-
ble, it was useless to have the springs so in their attachment
to the superior piece ; but experience soon taught that although
fixed, this latter was not constantly maintained in place, re-
ceiving as it did, shocks from the inferior, the eifect of which
could not be moderated. They were then articulated above
as well as below.
These spring heads all terminate towards the part to which
they should be attached by a small flat shield, and pierced
with a hole destined to receive the peg, around which the
spring should move, are formed of pieces of gold or platina
being generally fourteen or fifteen millimetres long, and about
one millimetre in diameter. Some are hollowed in the mid-
dle through their length, in order to receive the extremity of
the spring which penetrates it with force, and which we fas-
ten by a silk waxed thread, introduced through the end of one
of these tubes passed through the other, and confined on each
side by a double knot ; the others are solid, but those of their
extremities which should articulate with the spring are thin
and tapered in order to be introduced and screwed in the inte-
rior of this spring, which body held as in the preceding man-
ner, becomes permanetly fixed.
Some practitioners are satisfied, in making heads of springs
to simply bend upon itself a wire of platina from thirty to
thirty-six millimetres, but much harder than the wire of the
spring, and whose two branches are united and properly filed
for entering the body of this latter, leaving between them, at
the point where they are bent, an opening in the form of a ring,
intended, as in the other case, to receive the attachment of
the spring, which is an axle or rotation pivot.
As to this latter, it is the same, whatever may be the form
of the spring head ; but it necessarily varies according as it is
adapted to an osseous base, or to a plate, or mineral cuvette.
In the first case, it is simply a piece of gold or platina of about
one millimetre in diameter, and ten or twelve millimetres in
length, of which two-thirds are tapered in such a manner as to
496 OPERATIVE MEDICINE AND PROSTHESIS,
form a body of a screw intended to be introduced into the
substance of the base which is pierced for it. The part which
remains projecting from the floor of the base, a soldered burr,
and the exuberant pivot which should form the axis of the
movements of the spring is itself tapered, in order to receive a
small screw with a rounded head, or better, a drop of oil,
which we place on it when the screw head is introduced. In
the second case, that is to say, when the spring attachment is
to be fitted to a metallic base, it is soldered to this base, either
directly, or by means of a small simple plate, or moved upon
a vertical stem, and the overplus is arranged for receiving the
head of the spring.
The form of a swivel has been given to the terminal ex-
tremity of the spring heads ; it was then used by closing the
attachment of the spring with a screw. A second burr was
then soldered to its extremity, which left, between it and the
first, the necessary space for the rotation of the spring head.
But this method is less advantageous than that which con-
sists in making a continued stem, because the point at which
the two branches of the swivel touch does not oifer a sufii-
ciently united surface for giving the necessary facility to the
rotation.
Finally, with a view to make springs more movable in a
horizontal direction, if we wish it transverse, we have conceived
the idea of dividing the length of the lever which forms the
head with an articulated joint, whilst others have given to
them the form of a crescent, increasing the development of the
springs themselves. But these methods appear to us, to be
completely useless at the present time, experience having de-
monstrated that those which we have described, accomplish
perfectly the end that we had desired in using them.
Adjustment of Spj'ings. — One important thing remains to
be considered in the use of springs, that is the determination
of the precise point of the denture upon which they should
receive their support, and consequently be fixed. If they are
placed too far back, and exert too much effort in sustaining
the piece, which poises in front, in holding the two parts con-
stantly in place ; on the contrary, if they are placed either too
OR MECHANICAL DENTISTRY.
497
far in front or too far back they force the piece to leave the
alveolar border upon which it rests ; this is demonstrated by
experience and an application of physical laws to the solution
of the question.
Now, what are the rules that authors have established in
this respect? Maggiolo advised the insertion of the springs
in the middle of the two lines forming the sides of a square.
Confining the piece in such a manner that it would touch in
every direction the sides of this square. But it is evident that
if this plan would answer for a denture composed of two
pieces, with a development perfectly equal, it would not for
one of unequal pieces, because the point furnishel ov this
method of measuring being more on the anterior plan for the
smallest piece, the springs in this case would not correspond.
Oudet, desirous of solving the question in terms which
would appear very scientific, pretends that it is the geometj'i-
cal cettire of each branch upon which the springs should be
inserted. If by that this dentist means the centre of the
space comprised between two parallel lines passing, the
one behind the extremity of the piece, the other before the
central incisores, he has only repeated that which Maggiolo
has said, and the objection that we have made to the opinion
of this latter is altogether applicable to him. If, on the con-
trary, by a geometrical centre, Oudet means the middle of the
extent of each side of the piece, the necessary result of it is,
that this point would advance as much before this as the
curved part of this side would pass, in redressing the hori-
zontal line which would be supported upon the two central in-
cisores; but then the spring would be too much in front, inas-
much as it would, generally, correspond to the commissure of
the lips, nearly at the point which separates the canines and
the first small molares.
Delabarre, that part upon which we would expect a pro-
found examination of the question with which we are occu-
pied, has answered in too brief a manner, particularly for per-
sons who wish a statement of why and hoto^ in saying;* "1
* Work quoted, vol. ii, p. 448.
59
498
OPERATIVE MEDICINE AND PBOSTHESJS,
think that we should adopt the following as a rule, and which
we should rarely break, viz. to place the articulation of the
springs in such a manner that they could not be perceived. . . .
No reason should oppose that which I have here established/'
As to Maury, he merely* says, that "the only precaution we
should take to insure success in the use of springs, is to care-
fully select their true point of support," and to give as a prin-
ciple, that "the dentist will always do it when he is in the
habit of constructing these kind of pieces." Lefoulon is still
much less explicit and more accommodating,! for he expresses
himself simply in regard to it in these terms: "It is then
only by groping that we can find the proper place for the sup-
port of the springs."
For ourselves, we sum up our opinion in these terms : what-
ever may be their forui, they should always be placed in such
a manner that the two pieces of the denture should be held in
a perfect equilibrium, and this important condition can be filled
only in proportion as the two points of sustenation are con-
tinually perpendicular, the one to the other, even in the case
where one jaw exceeds very much the other in front. If it
would be necessary to point out precisely the place, we would
say, immediately behind the second small molar in the supe-
rior piece, and directly behind this same tooth in the inferior.
We conceive, however, that this perpendicularity of the axis
is not as rigorously necessary when the dentures may be fixed
to the remaining teeth; as to the support that these teeth give,
either directly or indirectly, it is always necessary to profit by
it, because much may be sacrificed to the desire of rendering
springs invisible and of no pain.
The difficulty that we experience in finding the precise
point of the denture upon which the springs should be placed,
and the disagreeableness which follows its fixation upon a
place where we are often obliged to change it because it is not
convenient, has given birth-to a method more complicated, it
is true, than those of which we have here spoken, but which
has this advantage over them, of permitting all the necessary
attempts for discovering this point.
* Work quoted, p. 386. t Work quoted, p. 430.
OR MECHANICAL DEXTISTRY.
499
This method consists in fixing the articulating pivot of the
spring upon a small plate of piatina cut square, but a little
smaller than the thickness of the base of the denture, and
pierced with a small hole at each of its four angles. This
plate, supporting the spring, is, at first, confined by wax, or
any other agglutinative substance, then changed, if it is pro-
perly placed. The place once correctly selected, we hollow
upon the base, (osseous base,) a slight notch for receiving it,
and we fix it permanently, by four small gold screws with a
sunk-head at least, if we do not wish to pierce it through and
through by the pivot itself, which would be riveted on one
side, and would form an axis on the other.
The extreme mobility of spiral springs has given to some
practitioners the idea of restraining their action only in the
place where they should move, by maintaining them in place
on the pieces which they should support, by means of small
hooks of gold or piatina in the spot in which they should only
act, and which they have designated by an expression not
less new than significative, viz. limitators.
However specious as this idea may be in theory, it offers
nothing very serious in practice, in regard to the end that those
propose who have sustained it, because the jaws exert always a
pressure upon the springs, so great as to prevent them from
deviating from the movements which belong to them. But if
these small fixtures are not useful, they are necessarily detri-
mental by the thickness they give to the piece, and the
pain their angles give to the parts which come in contact
with it. Also, we think it prudent to renounce it, and to sat-
isfy ourselves, when it is necessary to confine the action of
the springs above and below, by fixing in these two directions
a small piece of leather for it to rub against.
We have said, at the commencement of this article, that
springs, such as we have described, were intended to maintain
the two pieces which compose a denture, apart, and which
naturally approach in the occlusion of the mouth. We have
neither wished to say from that, that these two pieces should
be necessarily complete, nor that they should be equjal in
force, that is to say, for the number of the teeth. Very often,
500 OPERATIVE MEDICINE AND PROSTHESIS,
in effect, we have to replace the teeth of the superior jaw, and
some only in the inferior.
It is always by springs, such as we have described, that
pieces fit for filling each of these indications are maintained
in the mouth ; but the teeth which shall furnish the lever plate,
although perfectly arranged, each in its proper place, should
be united by a band, a kind of metallic plate, which, arranged
in a manner so as to apply exactly behind the dental arch,
forms, with the parts composing the piece, an assemblage suf-
ficiently solid to give to the springs a support completely
immovable. Tliis assemblage should even extend to the most
distant part of the alveolar border, in order to correspond to
the superior piece of the denture.
If the inferior jaw had preserved all its teeth, we solder for
each side a supporting band for the springs, and of which
there may be some question, with two rings embracing the
two or three last large molars, and its solidity might be assured
by means of spurs, which, dividing it in as many compart-
ments as there are teeth existing, would insinuate themselves
into the posterior inter-dental spaces, without, however, being
allowed to touch the gums; we name these pincer-springs.
For a long time the form of a die was given to these springs;
but in order to avoid, as in the use of the inclined plane, such
as were at first used, the accumulation of alimentary and other
matters, we give to them, at the present day, the form of a
night-cap, or of a diamond, by soldering upon their external
face two small metallic stems, which divide the outward from
the inward, and the inward from the outward, crossing upon
the summit of each molar, and thus counteracting the
pressure exerted by the spring, and, consecutively, by the
ring upon the inferior jaw.
This apparel, as we see, resembles in all points that which
we have described, and which we employ for giving a solid
support to the attractive bandages intended to maintain the
different ligatures by means of which we endeavor to straighten
irregular teeth, particularly those which are oblique in front.
The credit of the first idea of this belongs to Fauchard ; for
no person that we know of had thought before him of fur-
OR MECHANICAL DENTISTRY. 501
nishing the superior jaw with a complete piece maintained by
a reactive agent resting below upon an incomplete' piece, or
even upon a similar one. The following is a proof of it.
"We may," said he, "*adjust, likewise, in the superior jaw
an entire piece of artificial teeth alone ; for, in order to hold
this piece, it is necessary to place in the inferior jaw a similar
one, according as the inferior jaw has all, or only a part of the
natural teeth which may sustain and strengthen the piece
placed in the superior jaw. These circumstances have in-
duced me to invent a machine which, being arranged in the
manner that I had desired, was adjusted in the superior jaw
so that it might perform the same use as the natural teeth.
''In order to construct this piece, it is necessary to examine
the number of teeth that remain below, the size, situation and
the dimensions of the gums, &c. ; then we construct two
plates of gold or silver, about one line and a half in length
and a quarter of one thick ; tliese two plates, thus fabri-
ricated, we curve upon their largest face two half-circles,
that we may adjust, the one upon the anterior, the other
upon the exterior face of the gums of the inferior jaw. The
plate which forms the exterior half-circle should be longer and
more curved at its two extremities, according to the height
and thickness of the teeth and gums that it should embrace.
It is raised above the teeth, and is bent in the place where its
curvature should form an elbow. Upon this piece, thus con-
structed, we mount by springs that which should represent
the artificial teeth of the superior jaw. . ."
Finally, if in the most of cases the springs aroused in pairs,
we perceive in the meantime how we can employ but one, on
the one side, for maintaining two pieces occupying the depth
of the alveolar arches on this side, and upon which there ex-
ists no teeth which may give the necessary support behind.
We have made, not long since, a piece of this kind which
* Work quoted, page 261, &.c. The chapter from which this quota-
tion is extracted has the ibllowing title : Description and me of a curiam
machine c( imposed of a complete superior denture, united by springs with a
piece of gold or silver which embraces, by means of two half-circles, and of
two handles, the teeth of the inferior jaw.
o9*
502 OPERATIVE MEDICINE AND PROSTHESIS,
succeeded very well, for a lady who had lost all the left large
molars, and whose absence had occasioned a sinking of the
jaw, which formed a striking contrast with the opposite side,
so much so that it was but rational to suppose that she should
seek to remedy it. The two pieces were fixed to each alveolar
arch by crotchets embracing the small molars. We might, in
the same manner, employ this method for fixing a single piece
above, the spring resting below upon a similar one, which
should embrace the teeth still existing upon this side.
The Application of all that which precedes, ifi regard to the
Particular Construction of Various Kinds of Ordinary
Pieces of Artificial Denture.
The enlightened student who will read, with the necessary
attention all that which we will say in the course of this chap-
ter upon dental prosthesis, and who will see each of the
operations here described, practised, by frequenting the work-
shop of the dentist, ought not, it seems to us, to find himself
embarrassed with any kind of a piece, whether simple or com-
plicated, in the acceptation that we have given to these two
words. In all, in effect, he will be obliged,
1st. To take the most minute impression, and, conse-
quently, as rigorously exact as possible, of the toothless place
or places ;
2nd. To make the mould upon which will be adjusted and
stamped the supports of these pieces, if the supports are me-
tallic, or after which they will be sculptured if their bases are
of animal substances ;
3rd. To determine the nature of the substance that should
be employed in preference to all others for supplying the loss
which it shall remedy ; a determination which depends par-
ticularly upon an attentive examination of the mouth ; then
to unite the teeth to their bases ;
4th. Finally, to choose amongst the different methods of at-
tachment that which is most suitable for maintaining solidly,
and, particularly, without injury to the neighboring parts, the
piece permanently in the place it should occupy.
OR MECHANICAL DENTISTRY.
503
All these things we have studied with sufficient detail in
order to be applied to the plurality of cases, particularly those
which most commonly present themselves in practice.
Now, of what true utility would it be to give, as most au-
thors have done who have written upon the mechanical por-
tion of our art, separate examples of each one of these pieces:
pieces of a continued series, that is to say, composed of many
teetli juxta placed ; pieces of an interrupted or interspersed
series, that is to say, composed of teeth disseminated, with
spaces between them for those which remain sound or at least
standing; finally, pieces of mineral or human teeth, mounted
upon a base o{ sea-horse, or upon metallic cuvettes, <fcc. &c. of
what utility? none, excepting to increase the volume, and
uselessly to perplex the mind by fastidious repetitions.
Do we wish to have a proof, a completely unobjectionable
proof of this assertion ? we have one in the description given
by one of the first authors, Maury, for example, of a com-
plicated piece of many natural teeth mounted upon a base of
sea-horse.
'•When we wish to mount, says this author, natural teeth
upon a base of sea-horse, the first thing to do, is to adjust it
well in the mouth ; and in this respect we will not repeat that
which we have said in speaking of pieces sculptured on sea-
horse, the method of adjustment being always the same,
whether the piece will be furnished with natural or incorrupti-
ble teeth. Thus, then, after having assorted and selected
them, as nearly as possible, similar to those which they should
replace; after having sawed their roots to a proper height,
we place them upon the animal base in their respective posi-
tion, and maintain them there with a httle sealing wax. That
done, by means of agimblet mounted upon a drill, we form in
their roots, and at the base which supports them, a small hole
in which we put a peg m order to fasten them for the time
being, the one to the other, and we replace this peg sometimes
by a larger one, sometimes by two smaller ones, or even by a
screw," &c. &c.
What can we find in all this which would not be perfectly
understood without, and which would be of use to the stu-
504 OPERATIVE MEDICINE AND PROSTHESIS,
dent who understands all that we have said upon the adjust-
ment of hippopotamus pieces, and upon the choice, perfora-
tion and mounting of natural teeth: and what would be the
use, when one has devoted several pages beforehand to a de-
tailed article on ligatures^ plates, crotchets and springs ; in a
word, on the different methods employed for maintaining arti-
ficial teeth in the mouth, to add a particular description of a
piece.
"Artificial teeth, whose union constitutes complicated pieces,
may be fixed upon their base (the author, doubtless, wishes to
say, upon the alveolar border) by different methods of attach-
ment, sometimes in effect, we employ simple ligatures, some-
times, crotchets, or springs," &c. &.c.
The observation that we are about to make is no less appli-
cable to Delabarre than to Maury and others. We may judge
by this description of the construction of a denture of a con-
tinued series, which he calls a simple piece with enamel:*
"We select a piece of hippopotamus which has the proper
dimensions for filling the breach ; it is particularly necessary '
that it should describe the same portion of a circle as that of
the vacant space. We should prefer a hard not chalky enamel,
of a pure white and not blue, presenting a thickness with the
least possible projections. This piece should be higher than
is necessary, so as to be able to affect the incrustation, and
even to remedy the defects that might be made in working it.
We remove with a rasp or grinding apparatus, a portion of the
part not enamelled, preserving it only of a length of six or
eight millimetres for forming a base intended to rest upon the
roots, if the piece is to be attached with pivots ; or from twelve
to fifteen, if it is to be fixed by other agents. . . It is well, be-
fore advancing too far in the work, to try it upon the patient
in order to ascertain if there is no essential fault to correct. . .
We must not be satisfied in sculpturing the teeth, to cut them
clumsily, although they might be for those who had no idea
of human anatomy. The incisores should have the form of a
flattened angle, but swollen in front and hollowed behind,"
&c. &,c.
• Work quoted, p. 183, &c.
OR MECHANICAL DENTISTRY. 605
Notwithstanding some variations, necessary for the special
destination of the object, the description that Delabarre gives
of the method of constructing the piece opposite to that of
which we come to speak, that is to say, a denture of inter-
rupted series, of a single piece of enamelled hippopotamus, is
absolutely the same, as the following will prove:*
"When we wish to make a slanting piece from a single
piece of enamelled hippopotamus, we must select a piece
whose enamelled arch will be the same as that of the portion
of the mouth for which it is intended. In order to succeed,
we cut a pasteboard in the same manner as we would the
piece itself ; we cut it to receive the teeth upon the model,
making with it, the convex or anterior border. With a pencil
we trace the form of this pasteboard upon the piece of hip-
popotamus, having care to place the projections which might
be upon this substance in the places which should be cut off.
The rasp and grinding wheel are the proper agents for sketch-
ing it, which, being executed, will facilitate the incrustation
with the graver," &c. &c.
It seems to us, after having established the principles which
should serve as a guide under every circumstance, and having
observed with care each object which belongs to the construc-
tion of a piece, in afl the details appropriate to the diverse
usages that we may make of them, it would be useless to give
particular examples of each kind of piece. We will then con-
fine ourselves to the examination of certain objects which, by
their special nature, depart from the rules that we have pre-
viously given ; such are complete dentures and maxillary or
palatine obturators that are united. We regard that which
belongs to lingual, labial, nasal, or facial prosthesis altogether
foreign to the art of the dentist.
Exceptionable Pieces.
By this expression, exceptionable pieces, we do not wish to
say that the objects of prosthesis that we now designate, de-
* Work quoted, vol. 1, p. 248.
506 OPERATIVE MEDICINE AND PROSTHESIS,
part completely from the general rules that we have establish-
ed for the construction and adjustment of pieces which are
most frequently employed, and form those that we have called
ordinary pieces. For these, in effect, as for those, it is neces-
sary, first of all to take the impression of the parts, obtain
them in relief, construct the bases, fix the teeth there, and to
provide means for maintaining them in place; but the pieces
of which we shall now treat, depart so much from general
rules, as to require some important modifications, particularly
of detail in the application of rules, and we believe it right to
give a particular description of them.
Complete Dentures, vulgarly called Rateliers*
In all that we have said as far as the present, as much upon
the methods of taking impressions, as upon the manner of
using these impressions as faithful guides in the construction
of different pieces of artificial denture, we have always admit-
ted that the jaws were not completely deprived of their teeth,
and that the few that were remaining of them were always
sufficient, nevertheless, was it only one, provided that it had
its usual length ,t to appreciate the natural degree of widen-
ing of the two jaws, and consequently the length to give to
the artificial teeth with which we intended to supply them.
There exists several cases, unfortunately, very common,
where the alveolar borders are completely unfurnished.
In these cases, must we content ourselves with taking the
impressions of the two jaws, and stamping after these impres-
sions of plates upon which we will mount the teeth placed as
these are in the natural state, and of a height equal to those
that teeth generally have? Not exactly; because the jaws,
♦ We advise young practitioners to employ as little as possible the ex-
pression o[ralelier, in order to insensibly expunge it from the vocabulary
of our an.
t That which would not be if it was decayed in the superior part of its
crown, because it would then be too short; and which would not be if it
remained long without an antagonist, because it might elongate in ad-
vancing from its alveolus.
OR MECHANICAL DENTISTRY. 507
the inferior particularly, have experienced by the fact of the
total loss of the organs which furnish their borders, changes
of which it is of the greatest importance to notice exactly.
These changes effect both, in the shrinking or sinking of
their alveoli; in the inferior, upon the opening of the angle
which, as we have seen in the anatomical part, takes among
old persons the form it had in infancy, where the body and
branch of the bone unite themselves in an angle so obtuse that
they seem together.
The first of these two changes, the shrinking of the
alveoli, has for its result the overturning of the jointing
of the inferior jaw by the superior, because this sinking is
made from without inwardly, for this latter which shrinks a
little in diameter, and from within outwardly, on the contrary,
for the first whose extent then augments- a little. The other
change, that which results from the opening of the angle of
the inferior jaw, has for an inevitable effect: 1st to throw the
body of the bone forward, for the articulating condyle remains
fixed : 2nd to draw the two jaws near to one another, so much
as to efface in the whole length of their body the space which
separates them when they were furnished with teeth.
If you take then a complete denture the most ably executed,
but copied from the jaws of adults furnished with their teeth,
in a word, composed of bases perfectly horizontal upon which
will be implanted perpendicular teeth, and when you place
this denture upon the jaws which have undergone the trans-
formation that we have described, two things will happen ;
first the inferior denture will glide before the superior ; after-
wards the widening of the jaws by the molar teeth, whose
place had disappeared, wall be effected only by the painful
pulling of the masseter muscles, and other elevators of the
jaw.
We do not believe that the change in the form of the infe-
rior jaw is the result of old age, for it is rather the inevitable
result of the total loss of the teeth. Thus we see old persons
having preserved them, to have the angle of the jaw nearly
acute, and the chin scarcely projecting ; whilst we meet with
508 OPERATIVE MEDICINE AND PROSTHESIS,
many adults who have lost them all at an early age, and who
have nevertheless the entire physiognomy of old age.*
From thence follows the necessity for those persons who
wish to preserve the habitual expression of their physiognomy,
and to have the least appearance of decrepitude, of replacing
their teeth as they lose them.
Aware of these facts, the dentist who would have to con-
struct a complete denture, not as an evidence of art, but to be
applied usefully upon a person who was for some time com-
pletely toothless, should commence by taking an exact im-
pression, but each jaw separately ; a method preferable to the
habit that some dentists have of taking an impression of both
jaws at once in wax, and whose result rarely gives the true rela-
tions between the two maxillaries. He should then construct
these moulds, but he should be careful to articulate together
the two parts, although no tooth exists, he will be entirely
ignorant of what degree of space he should leave between
them ; the length of the whole of the two dental ranges will
alone regulate this widening.
The plaster moulds being made he should obtain those in
lead or in any other metallic substance, since it is particularly
for large pieces that we have established the necessity of it ;
he should stamp these plates, then adjust them upon the
gums, and afterwards establish them according to the rules
that we have heretofore established. Then he should attend
to the teeth. But what length should he give them, and how
should he establish this length in a satisfactory manner? It
is in this that the difficulty consists, for many reasons: first,
because the act which consists in taking a wax impression,
for stamping is so painful to many persons; second, because
in pressing them with much force, the gums might flatten, and
the mould is not as exact; third, in taking an impression
thus, the inferior jaw advances under the superior, and we
give it two large a surface.
* Delabarre, who knows this fact, has acted in opposition to himself in
saying, "it is not sufBcient to remove all the teeth to give to the face of
an adult the resemblance of old age ; from the fact it takes only the as-
peci of it,"
OR MECHANICAL DENTISTRY. 509
Some dentists, believing that they could overcome this dif-
ficulty by determining the medium height of the two dental
arches, in their different points in an adult, have estimated
that the widening of the jaws should be, altogethf^r in front,
thirty-eight millimetres, and altogether beliiud tweiity-fovir;
whilst others have accorded thirty-four, and even thirty milli-
metres in front, and eighteen or even fifteen behind, wishing
from thence not to change in too marked a manner the entire
physiognomy.
We think, that it is absolutely impossible to establish a pri-
ori, and even in a purely general manner, the precise degree
of this space; because in the place which corresponds to the
incisores, this degree may be regulated by a glance of the eye,
which satisfies better than all the measures that we can take,
that which agrees with the figure of the person ; and, towards
the posterior molares, by the opening of the angle of the jaw.
This opening will be as much more prominent as the com-
plete absence of the teeth has been more or less ancient, as we
shall demonstrate, as also as they have been lost at intervals
more or less distant from each other; for it will necessarily
suffice that some of them are left, particularly behind, so that
the transformation that we have mentioned shall not be ef-
fected.
Observe how the most of practitioners proceed, and this
which Lafoulon gives wrongfully as a new invention of his
own.* When the two plates, or rather the two bases, are per-
fectly adjusted, they solder or rather fix temporarily to the
middle part of the inferior plate, directly upon the median
line, a small metallic stem from thirty-six to thirty-eight mil-
limetres in length, directed vertically, in such a manner that
its superior extremity shall touch the middle of the opposite
* Work quoted, p. 408, &c. This author seems, however, to have no
idea of the iraasl'ormation that the angle of the inferior jaw undergoes
by the absence of the teeth, and, consequently, of the difference that
should exist between the length of the teeth of replacement, and the nat-
ural ones, since he expresses himself in speaking of complete dentures,
thus : "We have no need to add, that the teeth should be like those they
replace."
60
510 OPERATIVE MEDICINE AND PROSTHESIS,
plate; then they solder two other similar ones upon the lateral
parts, one on each side. They insensibly diminish them with
the file, nntil they are satisfied that they have the precise
height appropriate to the figure ; they then furnish these
sides, as far as the end of the base, with a roll of wax arrang-
ed as the dental range, but exceeding the stem from four to
five millimetres in height.
The two bases being then placed, they require the patient
to close the jaws so that the occlusion of the mouth will be
arrested by the pivot fixed from base to base. In this effort,
the wax will be necessarily stamped, and the point where it
stops this stamp gives, in the whole extent of the alveolar cir-
cle, the measure, but the /otal measure which the teeth should
have above and below united, a height which we then divide
between them as convenientlij as possible^ by measuring as
they say, the length of these teeth, after the middle of the dis-
tance which exists between the two cuvettes.
They continue thus : "These precautions being taken, both
pieces must be withdrawn with extreme care, in order not to
derange the wax teeth." Nothing better assuredly ; but they
add : ''When the whole is out without accident, we detach
the springs and place the inferior cuvette upon the plaster
mould which serves for their adjustment ; but, previously we
make some deep notches in the posterior part of this same
mould, and which we moisten. When it is thus prepared, we
form behind it a kind of very small trough with a leaf of lead
thin enough to be easily bent. In this trough we pour some
plaster which prolongs the mould by forming a heel there, in
each angle of which we form two holes, for receiving the heels
which will be adjusted in the superior mould."
"This is obtained in the following manner: we place
the superior cuvette upon the inferior, by applying the
extremity of the three pivots upon the small holes which
are impressed in the wax and whose office is to mark.
Upon this cuvette we place the mould which belongs to it,
and for fear that it might move, which should not hap-
pen whilst the plaster mould is drying, we fix it steadily with
several rows of very fine heated iron wire. Finally, we oil
OR MECHANICAL DENTISTRY. 511
all the part newly added to the inferior mould, and we pour
some liquid plaster upon both moulds at the same time. The
superior mould should by all means undergo the same prepa-
rations as the other mould so as to facilitate the adherence of
the new plaster."
Well, what does the practitioner that we have named think
of this metiiod, and which he gives as the fruit of an effort of
imagination entirely new ^ and which he believes a duty to give
to his confreres, it is defective from one end to the other.
This we can easily prove. First, the central pivot, intended
to sustain the cuvettes between which the wax should be
placed representing the teeth, is completely useless if we place
at the same time two pivots on the sides, because it is lateral-
ly and not before that the widening of the jaws should be ap-
preciated. On the other hand, if we place this pivot only,
it will not properly sustain the plates in place so that the
patient can make all the necessary movements to try the sus-
ceptibility of its attaining the end proposed, because the cu-
vettes would quit the alveolar border behind, or would not
adhere to it.
Then, not serving to represent both dental ranges, with a
single piece of wax, we should be obhged to introduce the
fingers in the mouth in order to maxalate and adjust the wax
above and below, and it is impossible to give to each dental
range the inclination which it should have. Besides, how
can we divide it in the direction of its height without chang-
ing the form which it should have ? Finally, in making only a
single mould for the two articulating pieces, we would experi-
ence the greatest difficulty in mounting the teeth as we should
have no fixed line to govern the arrangement of their cutting
edges.
Notice how we proceed : we solder upon each plate or base,
to the parts corresponding to the small molares, on each side,
a small plate of platina, from twelve to fifteen millimetres in
length, from four to six in height, solely to sustain the wax;
then we fill with two pieces of this substance, the space be-
tween them and the bases, holding these pieces, however,
higher than the metallic plates. We then require the patient
512 OPERATIVE MEDICINE AND PROSTHESIS,
to press lightly upon the wax; then we reduce it in height to
the degree wished, by cutting it with a curved knife which
removes it by pieces. We then arrange this wax for sustain-
ing the jaws ; give to the two layers that it forms in front, and
which we have had care to flatten with the fingers, the direc-
tion that the total mass of the teeth should have, and we as-
sure ourselves of the entire exactness of the whole, so far as
that the physiognomy has returned, that it can execute all
the functions which belong to the jaws, and finally, bite
square in every direction.
When this imitation of the complete denture is perfectly made,
and the two parts of wax which represent each a dental arch,
acting well in every point the one upon the other, we make a
mark upon their anterior part, so as to recognise their central
point, which represents the two great incisores above as well
as below ; we do the same upon their central parts, so that
they may always be replaced in the same relation that they
had in the mouth. This second lateral mark should be re-
peated upon the base and made, as much as possible, upon
the place that is intended to be occupied by the springs.
Then, as the bases are metallic, we slightly heat them at
the concave part by the alcoholic lamp, then draw carefully
from them the two circles of wax which covers them, and we
fix then a small plate intended to receive the spiral spring.
We then replace the wax with care in the mouth upon their
plates, and fasten the springs there temporarily, so as to assure
ourselves of the regularity of their action. In regard to the
determination of the precise point upon which they should be
placed, we were sufficiently occupied with it, in speaking of
the general means of holding the different pieces of artificial
denture in place, and particularly in treating of springs.
These precautions once taken, and the height of the two
dental ranges obtained by that of the two pieces of wax which
represent them, we make an articulated mould apart for each
jaw. In order to do that, the springs being removed we place
each plate furnished with its wax upon its own mould; we
then make upon the internal part of the mould, in about the
the three posterior quarters of its extent from the front back-
OR MECHANICAL DENTISTRY.
5i:
wards, a deep triangular notch ; then cover this interior and
posterior face of the wax with a little oil. Then we envelope
the mould through all its circumference, as for an ordinary
plaster mould, with a band of very thin flat lead, or simply of
pasteboard, of double the height of the mould; then we pour
some diluted plaster, which filling all the concavity of this
latter, touches it everywhere, less necessarily at the place where
the band of wax occupies all its circumference. The counter-
mould being dry, we separate it, remove the wax and find, in
placing the counter-mould in the mould, the precise place the
teeth should occupy.
In regard to the method of fixing the teeth (which, may be
said in passing, never exceed twenty-eight,) there are three
things to be considered ; the direction that must be given to
them, the order in which they should be placed, and their at-
tachment to the base which should support tiiem. That
which we have said of the shrinking of the alveoli of the jaws
shows us that those of the base should be directed a little
within, so as to correct the efljects of this shrinking which
operates without, and those above outward, for the opposite
reason. We also think that it is always better to give to the
teeth of a double denture a height a little less than that which
the natural teeth have, for this very simple reason that the piece
will be as much less apparent as it is less thick.
In regard to the order in which they should be placed, that
which we have also said of the effacement of the angle by
which the branches of the inferior jaw are united to the body,
would make it appear that it is first on this, that is to say, by
tlie molares,that it would be well to commence, since it is the
space that we leave between the jaws in the depth of tiie
mouth which will regulate the length which the anterior teeth
should have. But as this space is always rigorously obtained
by the pieces of wax, the central incisores should be placed
first, and then themolares, not fixing them definitively, until
after having tried their position, not only upon the mould but
even upon the month of the patient.
Finally, it is, particularly, for teeth making a part of com-
plete dentures that we sustain them behind, when they are
60*
514 OPERATIVE MEDICINE AND PROSTHESIS,
mineral ones, which maintains them soHdly united together,
and at the same time on the base ; but it is then useful to
bring them as near as possible together, so that this band may
not be perceived.
All that which we have said applies, as we easily see, only to
dentures with metallic bases ; but when we construct them with
bases and teeth of animal substance, or to speak more posi-
tively, of hippopotamus, we should take the following course:
Take the separate impression of each jaw, have the relief
mouldsof both, (moulds of plaster only, and notof metal, which
becomes useless, since we have nothing to stamp;) these two
moulds obtained, we take a second impression by means of
two pieces of wax applied upon each alveolar arch ; but then
to have altogether the hollow of the alveolar border, as for
that which served to furnish the plaster moulds, and the
heiebt of the teeth, as for metallic cuvettes. This is, doubt-
less, that which Maury wished to say by this phrase, by
which he commences the description of a denture with a sea-
horse base : "We commence by taking, separately, two impres-
sions of both jaws," &c.
However that may be, we should make the wax reach each
side of the alveolar border, precisely at a level with the base,
and make it encap the gums exactly, as this latter would.
Finally, we obtain, as for metallic bases, a counter-mould so
as to have always a method of appreciating the true height
of each denture, by holding it, nevertheless, a little more dis-
engaged towards the internal face of the teeth, so as to cor-
respond to the great thickness which the base inevitably has
in this case.
This being done, we take the piece of hippopotamus which
we intend for each denture; cut it exactly upon the piece
of wax representing the teeth, leaving it two millimetres long,
so as to provide for the slight deperdition that it might
experience in this direction by the intersecting of the teeth
where they are regularly cut; we present it upon the plaster-
mould, and incrust its base which should bear upon the alve-
lar border, by means which we have previously given ; then
we try it in the mouth of the patient, each piece separately,
OK MECHANICAL L)Ex\TISTRY. ifi'J
then both together, so as to estabhsh their true relations ; we
mark upon each piece, vertically, the line which should sepa-
rate the central incisores, and we withdraw them from the
mouth in order to trace with a crayon the portion which
should be devoted to each tooth and which we then sketch.
We do not proceed farther without again trying the den-
ture, so as to remove by the rasp or graver those points which
might be superfluous. As all that which relates to each piece,
besides the teeth, is obtained and acts only by the relations
established between them, we may maintain them united by
a little wax interposed upon the different parts of the surface
where they touch and are withdrawn in this position, then
placed upon their primitive moulds. We then make from
these an articulated mould, that is to say, only by the addition
of a certain quantity of plaster added to each mould and ar-
ranged as a projection in the one, and as a cavity in the other,
as we have previously said, we place these two pieces in sim-
ilar relations to those in which the mould and counter-mould
have been put, which have served to give to each dental
range the proper height. To finish the teeth remains only to
arrange them in such a manner that in front the inferiors cross
under the superiors, and that, upon their sides and behind,
the tubercles made upon the triturating face fall just in the
depressions made in their antagonists.
Finally, when we wish to mount human or mineral teeth
upon hippopotamus bases, intended for a complete denture, we
proceed exactly as we do for pieces whose bases and teeth are
hippopotamus ; only, when the piece is properly cut and cor-
responds exactly to the other piece, we mark on each side the
j.lace intended for the two large molares, then we remove all
the intermediate portion intended for the ten teeth that we
propose matching. We sculpture the molares in such a man-
ner that their tubercles indent well, and mount to the height
obtained, the human or mineral teeth, according to the rules
that we have given.
We are particular, also, we repeat it in opposition to the or-
dinary opinion, not to fix the springs permanently to the bases
before placing the teeth irrevocably there: the regular action
515 OPERATIVE MEDICINE ANU PROSTHESIS,
of these springs being one of the most important points in the
use of this kind of piece, all should, so to speak, be sacrificed
for it ; in such a manner, that if the points upon which these
springs should rest being well ascertained, those which were
tried, before the piece was furnished with its teeth, not seem-
ing sufficiently strong, we substitute for them others of the
same length, but more resisting,
in regard to the question seriously agitated by some den-
tists,* whether the springs should be gold, brass or iron, it is
necessary to be very fastidious to suppose that some practi-
tioners could be found so ignorant of indispensable matters in
the exercise of their profession, and so prodigal of their time,
as to amuse themselves with calculating the results with brass
or iron springs in comparison with gold.
We have noticed, that all the details relative to the con-
struction of a complete denture enters into the general con-
siderations with which we were previously occupied, and a
new development of which, here, would form a useless repe-
tition. We might, however, establish, upon this subject, un-
der the form of propositions, the five general rules which loi-
low:
1st. In the construction of a complete denture, every thing
should be so arranged that the two pieces of which it is com-
posed, reaching as far as possible in the mouth, fill all the
alveolar border, which they exactly encap;t that, touching
every where the soft parts, in the midst of which they should
habitually rest, they will be most intimately united to them
and follow their various movements without experiencing any
unexpected shocks.
2dly. The action of springs is as much easier, and more
regular, as the superior piece is lighter, and as the inferior is
heavier. It is also for upper pieces that cuvettes of gold are
preferable to those of platina, and even for which palladium
* Lefoulon, work quoted, p. 406.
fTiiis does not destroy that which we have said of the propriety of
putting only twenty-eight in complete dentures, the two lastmolares being
generally formed of a single piece.
OR MECHANICAL DENTISTRY.
517
might find an useful application; whilst it is for lower ones
that bases of hippopotamus, or cuvettes of platina, particularly,
are fit: the first, where the alveolar borders have experienced
a great depression, the second where this depression is not
very prominent.
Sdly. The superior piece would be as much more solidly
maintained and easy to support, as it would reach the alveolar
border nearer on the internal side, and as it approaches nearer
the palatine vault, without, however, advancing upon this lat-
ter, because it would disguise the taste to no purpose, and
would impede the movements of the tongue.
4thly. Experience has taught us that too much importance
must not be attached to the advantage that author's be-
lieve bases of hippopotamus have, because of their mild con-
tact with the alveolar borders and gums. Persons who make
use of complete dentures, habituated in general so readily to
metallic cuvettes, that one has frequently erred in depriving
these latter of the inappreciable merit of being unalterable.
We, also, do not hesitate to furnish most of our hippopotamus
bases with a very thin metallic leaf, a kind of cuvette^ which,
increasing the weight of the piece very little, gives it a solidity
and permanency which it cannot have without.
5thly. It is, particularly, in regard to the construction and
adjustment of these pieces in the mouth that it is important to
know, that sc«ne persons, for whom they are intended, hope
in this case to be able, by some movements of their jaws, to
correct certain vicious conformations to which nature has sub-
jected them, but nearly, always, then, to the detriment of the
relations in which the dentist had placed the two pieces com-
posing the denture.
From thence serious difficulties often result which we may
avoid, by plainly refusing to yield to the whims of the patient,
or by warning him of the result obtained. We have often been
styled judicially arbitrary in similar contestations, and we
have, more than once, been compelled to judge contrary to
the pretensions of our confreres, whose pieces were perfectly
made, but which, by an excess of complaisance, or a want of
attention, had adjusted these pieces in conditions which soon
518 OPERATIVE MEDICINE AND PROSTHESIS,
rendered them impossible to be supported, and rendered them
completely useless to those for whom they were intended.
The fear of a similar disagreement should not, however, pre
vent us from condescending to the wishes of patients, when
the rectifications that they require would not affect the ad-
justment of the piece, nor offer a possibility of its preventing
its daily use.
Maxillary Obturators.
In the description of the different kinds of artificial pieces
which we have examined, we have always supposed that
either the osseous parts in which the teeth were naturally im-
planted, existed, or that these parts had not undergone any
diminution which it was not easy to remedy, by giving to the
osseous or metallic bases a sufficient thickness. But there are
cases existing, in which the teeth and a portion of one or the
other maxillary which receives these are wanting at the same
time. Our art, as is well kuown, is not altogether unavailing
in accidents of this sort, which, unfortunately, are very com-
mon, and which, although concealed by the soft parts, from
the injury which it is at once anxious to repair, constitutes no
less, in many instances, very inconvenient deformities, prin-
cipally by the difficulty caused by the preparatory work that
the aliments must receive in the mouth, or, that which is no
less serious, the articulation of sounds.
Fauchard thought to remedy these losses of substances,
and, although the pieces which he employed for this purpose,
had neither the precision nor resemblance of those constructed
at the present day, they accomplished the same end. If Dela-
barre had read with more attention that which this master of
the art has written upcfn the subject, he might have seen that
all the pieces which he has employed in the cases of which
we treat, were not sustained with nasal wings; * notice the
following literal quotation :
"I was consulted some years ago by a lady of the province,
•Vol.2, p. 318.
OR, MECHANICAL DENTISTRY.
519
who had lost the four incisor teeth of the upper jaw, by ne-
glected caries, which, in consequence, had also destroyed a
part of the superior maxillary bone. * * * It was on this oc-
casion that I conceived the idea of constructing a plate which
should,* at the same time, serve as a support for the teeth and
an obturator. I composed this obturator of a plate of ivory ;
the tooth of a sea-horse, however, when one can be procured,
is preferable ; but the seam which divides this tooth through-
out its whole length, renders it difficult to obtain a piece of
sufficient thickness for many artificial teeth. To this plate
which I adapted to the palate, I left on its convex part, a
small eminence pierced at its summit for the attachment of a
sponge. I next constructed four artificial teeth, which I at-
tached so perfectly to the canine teeth, that the plate was se-
curely adjusted, and accurately covered the hole in the palate,
whilst the artificial teeth which were contiguous, fitted so well
the breach of the natural teeth, as to exactly imitate them and
supply their functions."
The dental obturator, described in the Getieral Journal of
Medici7ie,f constructed by Fauchard, for a man who had
lost the two central incisores, the lateral incisor, the canine
and first right molar, with all the part of the superior max-
illary bone in which these teeth were implanted, a portion
of the mental apophysis, and nearly half of the middle
anterior plate of the palatine vault, was merely a copy of _
Fauchard's, which we have just described. Finally, in-
stead of fixing it simply to two neighboring teeth, as the
latter, this obturator had the immense inconvenience of main-
taining itself by reacting agents, which exerted upon the lat-
eral teeth of each side an eflfort of repulsion more liable to
loosen them than the ligatures of Fauchard ; and that with
the advice of Duval, who reported upon this obturator, and of
Delabarre's, who represents it in his work.
Whatever may be the character of the first artificial pieces
*'
^ This observation of Fauchard proves, without doubt, as we have
already remarked, that he knew and had used the tooth of the sea-horse.
t Vol. i, p. 386.
520 OPERATIVE MEDICINE AND PROSTHESIS,
the impressions which may be taken at the present day, permits
them to be made with an accuracy that cannot be excelled
When the loss of a portion of the alveolar border and neigh-
boring part of the maxillary bone only, is to be remedied,
when there is no communication with the nasal fossse, if it is
in height, as is most frequently the case, the hippopotamus is
the most suitable substance that can be employed, because it
is more congenial to the parts, and can be more easily adapted to
them, with the exception of mineral or natural teeth. As to
the means of maintaining these pieces, the crotchets, acting as
springs, and supporting themselves by as great a number of
teeth as possible, are the only ones which it is necessary to
employ.
Delestre, a surgeon dentist of Paris, presented to the Royal
Academy of Medicine, some two years since, a piece of this
kind, intended to replace in the mouth of an invalid, the loss
of the external table, only of a portion of the superior maxillary
which had carried with it many of the anteripr teeth. Being
retained in its place, it perfectly accomplished the object for
which it was designed. This piece had, as we can see, a
strong analogy to the piece which we have spoken of in an-
other place, but with this difference, that our professional con-
frere had remedied only the loss of a part of the anterior table
of the superior maxillary, embracing only a portion of the al-
veolar border, whilst we had a large portion of substance to
supply, and another indication to fulfil; namely, to close an
opening into the maxillary sinus.
If the loss of substance is more common to the superior
than to the inferior jaw, it must not nevertheless be expected
that it will never be necessary to construct an appliance only
for the first, it is in truth easy to conceive that a number of
circumstances may, as a wound from a gun, a cancerous af-
fection or necrosis, that carry off a portion of the inferior max-
illary, and render it necessary to fill the space that may result
from it either by remedying the sinking down of the soft parts
less apparent, or by giving to the bone more solidity, or sim-
ply by supplying to the denture, the part which had disap-
peared with the loss of the bone, or, finally, by preventing the
OR MECHANICAL DENTISTRY. 521
accumulation of alimentary substances in the cavity which
would of necessity be constantly lodged there.
Authors, however, furnish no example of a piece of pros-
thesis of this kind, Delabarre, doubtless, had no occasion to
construct one of this sort, for in the part which he has devoted
to the subject, he makes no allusion to it.* Moreover, we
think, he completely deceived himself, when he said that
Jourdain had occasion to apply one in a case of spina ventosa.
"VVe have read, with all necessary attention, what Jourdain
says of spina ventosa of the inferior maxillary, and we find
nothing that authorises the belief that the idea had occurred
to him.
In short, of the two cases which this author relates, in his
treatise upon the diseases of the mouth, he terminates the
first, by saying, that after he had removed the tumor, although
the bone, so to speak, became cartilaginous, he believed all
violent action should be avoided, "the body of the bone was
no more than a shell." The second case was that of a young
lady of twenty-seven years, which he treated as in the pre-
ceding, but upon which he applied no kind of an obturator,
since it disappeared immediately after the operation, without
which it would have been impossible to have determined
the consequence of the disease which had been thought
mortal.
More fortunate than our predecessors, we can supply the
lack of their silence, by relating a very remarkable case of this
kind which fell under our observation a few years since. The
subject of this case was a man from forty-five to fifty years of
age ; it originated from a violent blow received upon the left
side of the lower jaw, causing a progressive tumefaction ac-
companied by dull pain. The five molar teeth of this side
loosened, were successively removed, and soon all the anterior
table of the alveolar border detached itself from the body of
the bone, leaving exposed a vast cavity, from thence and the
blackish osseous lamela and cells flowed a fetid matter. Not
willing to take the advice of his own physician who recora-
* Work quoted, p. 312.
61
522 OPERATIVE MEDICINE AND PROSTHESIS,
mended the resection of the diseased portion of bone, he went
from iiis native city to Paris, in order to consult some of our
celebrated surgeons there. He returned from there home, and
merely contented himself with using many times a day,
aromatised, in the cavity, an enormous ball of cotton, which
was found in his jaw. His physician decided, however, to
level the wound of it by destroying, with a caustic, all ine-
quahties and soft parts ; this wound from thence took a more
favorable aspect, and he returned to Paris, but not for a surgi-
cal consultation, but merely to know if he might not have an
artificial piece to fill the cavity of his jaw, which not only af-
fected his pronunciation, but which formed a hollow in which
alimentary particles accumulated and tainted the mouth by
their speedy decomposition. It was at this time that he ad-
dressed himself to us, and gave us the foregoing facts.
This cavity, extended from behind forwards from the union
of the branch of the maxillary to unite its body to the canine,
and proceeding from above down the line which continues,
upon the external face of the maxillary, the anterior border of
the coronoid apophysis, even to the mental foramen, was
sufficiently deep to receive alone the middle part of a pigeon's
egg. We commenced by filling it with a piece of soft wax
in order to make it as nearly as possible upon a level with the
neighboring parts, and replacing the them as much as pos-
sible, in their natural state; then, after having taken the im-
pression of the whole of the jaw, we obtained a mould of plas-
ter, upon which we adjusted a plate of platina forming a kind
of vault which adapted itself exactly to the contour of the
opening. We then soldered to its anterior and posterior parts
two bands of the same metal, reuniting tliemselves in order to
form upon each molar of the opposite side, a metallic box
which perfectly encapped them, giving to all the apparel a
great solidity.
This fundamental indication, essential io stop up the opeimig^
being filled, we sought to fill that which was very secondary,
accessory to restoring to the diseased part its ordinarij form.
In order to do that, we simply fixed upon the plate, commencing
from the place which corresponded to the alveolar border, a
OR MECHANICAL DENTISTRY.
523
piece of hippopotamus, upon which the five absent molar teeth
were marked. All was adjusted in order that the piece might be
removed at pleasure, its weight and the precision of its adjust-
ment, giving it a solidity which we unfortunately obtained
only, in the superior jaw, by making points of support, of the
crotchets whose daily removal would undoubtedly injure
the solidity of the teeth to which they were applied.
We had an opportunity of seeing the subject of this opera-
tion, seven or eight months after the application of the obtu-
rator which we have described, and we have seen with satis-
faction that it had accomplished not only the desired end, but
still more the cavity which it covered was insensibly filled in
with fleshy granulations.
Palatine Obturators.
The idea of filling the opening that may cause in the pala-
tine vault either a congenital division of the bone of the palate,
or a wound or any disease whatever of the osseous system, as
those w^hich so often result, as wounds of fire-arms, and
syphihtic diseases, is certainly a very ancient idea. The
construction of mechanical apparels as a means of remedying
these accidental openings has long since been given to sur-
geon dentists ; their conformation and the relations that they
have with the teeth, by the irregularities that the deformity
produces in the order of these, or by the support that these
apparels receive from them, causes them to enter at the pre-
sent day more than ever, into the boundaries of our art; we
shall now enter into details relative to their construction, and
the rules which should govern their use.
Authors, generally, agree in regarding Ambrose Pare, not
as the first surgeon who sought to remedy the numerous in-
conveniences which result from this communication with the
mouth and nasal fossae, but only as the one who gave, in this res-
pect, the most precise rules. They have reason to do this : for, as
Cullerier* observes, the fact, Alexander Petronious wrote about
* Dictionary of Sciences Medicates, t. xxxvii, art, Obturateur.
524 OPERATIVE MEDICINE AND PROSTHESIS,
fifteen years before Ambrose Pare.* "If the decayed bone of
the palate falls of itself, or if we extract it, the pronunciation is
altered so much so that the patient can scarcely be heard. But
it is possible, in certain circumstances, to repair this loss ; for
example, when there is only a hole in the palate, we can stop
it up with cotton, with wax, with a gold plate or in any other
way that the genius of the artist suggests, having care to give
to these instruments the same concave form as the palatine
vault."
However, the method that Ambrose Pare advises is now
with reason altogether abandoned. It consists simply in "ap-
plying against the hole a plate of gold or silver, maintained
by the introduction of a sponge attached, as he says, to a stem
and retained by a screw. The sponge being dry, when we
place it upon the plate, swells by the humidity of the nasal
cavities and prevents the fixture from falling."
This method of prosthesis had, as we see, two great in-
conveniences. One consists in this, that the sponge, in im-
pregnating itself with nasal secretions, soon gives an infected
odor ; the other is this, that the presence of a strange body in
the accidental opening, particularly of a body constantly sus-
ceptible of dilating, would not only oppose its occlusion, but
would, on the contrary, continually favor its enlargement.
In every case if the sponge is only of a thickness sufficient
to easily enter the opening, the fixture would be liable to fall ;
or when it was sufficiently large to form, being humid, a pad
sufficient to support this apparel, it would exert a painful
compression upon the edges of the opening.
Fauchard obviated the first of these two inconveniences by
an obturator of very ingenious mechanism, to which we have
given the name of an obturator with iDings. "It is composed
of a plate, stem, two wings, two pivots, a vice, a screw and a
key."t The plate is intended to fill the opening by the side
of the mouth, the two wings to lay upon the superior face of
the walls of this opening in order to fill it on the side of the
* De Morbo Gallieo, printed in 1563.
t See vol. ii of his work, p. 293, &c.
OR MECHANICAL DENTISTRY. 525
nasal fossae, the vice to make the wings descend down until
they hold the edges of the opening closed between them and
the plate that they surmount, the screw to hold the vice fixed
at the necessary point ; finally, the key to move the vice.
"Before applying this obturator," says its inventor, "it is neces-
sary to raise the wings sufficiently to bring them near together
so that they may occupy as little space as possible ; this would
faciUtatc their introduction into the hole, or breach of the
palate. Once introduced it is necessary only to adjust it by
means of the key.
However ingenious this apparel may be, it obviates only,
one of the inconveniences attached to obturators with simple
sponges, that of preventing an accumulation of nasal mucosi-
ties in the sponge which cause an unpleasant odor, and con-
stituted their principal bulk ; but, as it is an incassant obstacle
10 the occlusion of the opening by the compression that the
edges of this solution of continuity experienced by the wings
and plate, between which they were applied.
Practitioners perceiving this difficulty, were a long lime oc-
cupied in simplifying the work of Fauchard ; from thence we
have the bolt obturator, the obturator with branches^ and the
obturator with a shank, and many others more or less ingeni-
ously combined, but all in two plates, or rather two super-
placed metallic surfaces, between which the edges of the
opening were enclosed. Finally, the obturator with a hood
or drum, which, if it had the inconvenience of filling entirely,
or in part, the opening as the preceding ones, exerted, at least
no pressure upon the edges ; it was the same as the gold plate
advised by Jourdain,* and, which applied upon the opening of
the palate that it overlapped on each side, was maintained by
a stem of the same metal, "bifurcated in such a manner as to
pass each nasal opening and then turn out upon each side of
the jaws," &c.
But at that moment, unfortunately too near to us, when
dentists perceiving all the importance and extent of their art,
enlightened by the torch of physiology, and, raising them-
* Work quoted, vol. i, p. 449.
61*
526 OPERATIVE MEDICINE 'AND PROSTHESIS,
selves to the height of general pathology, they discover that
if, in the application of palatine obturators, the occlusion of the
opening, by which the mouth and nasal fossae communicate
with each other, was an important indication to fill, it would,
in the meantime, never be to the prejudice of the tendency
that nature unceasingly repairs the injury which our organs
accidentally experience. A principle was thus established
for us that, whatever importance the mechanical question may
assume, in this occurrence, it was, however, but a secondary
thing, completely subordinate to the pathological or medical
question.
From this eminently rational view, of leaving the openings of
the palatine bones free in order not to obstruct the tendency that
they have to fill, juxta-placed obturators have come into use ;
tliat is to say, simply applied, over the opening against the
palatine vault, the only ones which should be employed.
We should remark, to the honor of our art, that this useful
reform belongs properly to dentists. Read, in effect, the word
obturator in the most of modern medical dictionaries, and you
will see with astonishment that not one of the practitioners
who have written this word have even presented the necessi-
ty of widening the way opened by Fauchard, since all indis-
tinctly advised from obturators introduced, but not applied.
And in the meantime, "before regarding," says Delabarre,
with reason, "the cicatrised perforations of the palate as being
of a nature not to diminish in diameter, are practitioners well
assured if it is so? I do not believe it, for positive proofs attest
the contrary ; for the same reason that holes made in the cra-
nium with a trepan, close nearly always in time, and those of
the palate likewise decrease. Bourdet has observed it in
many cases, and if my assertion would add any weight to his,
I could assert the same thing : it would then be well to guard
against applying a machine whose vicious construction might
oppose a cure which nature endeavors to make, at least, in the
majority of cases."
In effect, Delabarre might have added, that Cullerier, in the
great Dictionary of Medical Sciences, describes only the obtu-
rator with wings of Fauchard, and speaks of obturators taking
OR MECHANICAL DENTISTRY.
627
their support from the teeth, only on the occasion of those
which necessitated the losses of substance which interested, at
the same time, i\\e palatine vault and the alveolar arches. But
the following phrase clearly shows that this author admitted,
that obturators maintained by wings, were the only ones em-
ployed in ordinary cases, and that those with crotchets were
appUed only in exceptionable ones : "As the disease which
penetrates the palate attacks also a portion more or less con-
siderable of the alveolar and dental arches, to the obturator of
which we speak, a ratelier has been added, which is fixed by
the same mechanism, and which may, to attain solidity, be
fixed to the neighboring teeth."
The au thors of the Dictionarie Abrige des Sciences Medicales,
in the number of which were Sanson and Begin, afier having
developed the inconveniences that obturators with sponges
have, express themselves thus: "These reasons have induced
us long since to prefer mechanical obturators. The instru-
ments of this kind which we fabricate at the present day, as
the others, with a more or less extensive plate, susceptible of
applying exactly to the contour of the opening that it closes,
and arranged in such a manner that it continues the general
plan which supports it. From the surface of this plate, which
corresponds exactly to the naso-buccal opening, raises two or
more wings, which were held back by a simple mechanism,
and which, then, lower themselves by means of a stem with a
screw, which a mounted key moves, applying from the side of
the nasal-fossae, upon the edges of the solution of continuity."
Lagneau, in the Dictionary of Medicine, one of the last
published, and to the editing of which the most distinguished
practitioners of our time have participated, after having spoken
of obturators with sponges, whose use at the present time is
not a-eneral, as this honorable practitioner thinks, but aban-
doned completely y Lagneau, we say, proposes as the best, the
most convenient, and that which he believes the most ordina-
rily applied, a mechanical obturator, which he minutely de-
scribes and which is, in fine, nothing more than an obturator
with wings as we know.
We see, with pleasure, from a discussion which took place
528 OPERATIVE MEDICINE AND PROSTHESIS,
in the academy of medicine, that the most distinguished sur-
geons commenced to widen this way, and to partake of the
advice that surgeon dentists have long since given, and which,
as far as regards ourselves, has always been our rule of con-
duct.*
The circumstance which provoked this discussion was
the presentation, by Blandin, of a young man upon whom
this honorable professor had performed a very extended di-
vision of the palatine vault. This, (palatine vault,) at least
in the four-fifths of its extent, being operated upon ac-
cording to the procedure of Roux,t slightly modified, the pa-
tient presented then but a hole towards the middle of the
palate, an obturator, says, Blandin, sufficed to regulate his
speech.
Velpeau, after having examined with attention this patient,
and applauded the success of Blandin, thought that the hole
of the palatine vault might yet obliterate itself, and demanded,
in consequence, of his learned colleague, if he did not believe
that the obturator was an obstacle to the closing of this open-
ing. This latter found the remark very just, and he declared •
he would warn the patient of it. Gerdy was even of the
opinion that, in similar circumstances, we should not only
cease using the obturator, but that it would be of the greatest
utility to aid the closiiig up of the edges of the palatine open-
ings by applying a bmidage or an appropriate support.
We say, that the patient here spoken of had been operated
on according to the procedure of Roux. We do not pretend
from that, as has been believed up to the present, that Roux
was the first who had performed the suture of the palate in
* See the account rendered of the session of the Royal Academy of
Medicine, on the 20th of September, 1842, discussion between professors
Blandin, Velpeau and Gerdy.
fSee his Treatise upon Siaphyloraphy, or Suture of the Wing of the
Palate, in 8vo, Paris, 1825, with figures. The operation which the sub-
ject of this memoir has carried away, in his time, the great prize of sur-
gery decreed by the Institute, and forms, without contradiction, one of the
most beautiful scientific achievements of the actual chief surgeon of the
hotel-dieu.
OR MECHANICAL DENTISTRY. 629
France. Roux,as every one now knows,* had only the merit
of giving to this operation a rank amongst the surgical opera-
tions admitted as rules and elements of the art. But we direct-
ly claim it for our specialty, since it was practised with all
possible success, in the middle of the last century, by a dentist
named Le Mounier.f This proves this explicit passage, con-
tained in a collection published in 1764, by Robert, under the
title of a Treatise of the Principal Objects of Medicine : "A
child had its palate cleft from the veil to the incisor teeth, Le
Mounier, a very able dentist, tried, with success, to unite the
two edges of the cleft, he made many sutured points in order
to hold them together, and then removed them with the cutting
instrument. An inflammation followed, which terminated by
suppuration, and was followed by the union of the two lips of
the artificial wound. The child was perfectly healed." This
quotation should follow, it seems to us, in order to make Roux
and Graefe, of Berlin, agree, who are disputing the priority of
this operation.
The principle after which palatine obturators should be con-
structed, being once admitted, what form should be given to
the obturating plate ? This is a question which we should not
have made, while it is natural to think that this form should
be that of the palatine vault itself, if we had not seen it made
in a pamphlet published about two years since.|
The author of this pamphlet, having an obturator to place,
prepared to make his plate slightly rounded in the vault, when
Dr. P. . . ., who had addressed the patient, imbued, even with
excess, with the necessity of impeding the edges of the naso-
palatine opening with nothing, made him lower this plate.
The opening cicatrised very promptly ; but as our young con-
frere remarks with reason, is this to the absolute defect of con-
tact of the plate and the edges of this opening that it is rea-
* See the works of Velpeau, Vidal de Cassis, &c.
jThis practitioner has published many works upon our art, among
others, a Dissertation upon the Diseases of the Teeth, printed in 1753, and
reprinted in 17b3; then a Letter lo Mm-ton, in 1784.
I Summary upon the Straightening, &c., followed by some Reflections
upon Obturators of the Palate, by J. N. A. Schauge. Pamphlet in 8vo.
530 OPERATIVE MEDICINE AND PROSTHESIS,
sonable to attribute this advantageous result? No, we reply
with him, because all the accidental perforations which nar-
row and close take the form of a funnel. From whence it re-
sults that by giving to the obturating plate a depressed form,
even simply horizontal, we increase the facility with which
the nasal mucosities accumulate between it and the palatine
vault, and impede the movements of the tongue ; and that
without any compensation as to the occlusion of the opening.
However that may be, we maintain obturators, juxta-placed,
by ligatures surrounding on each side, the nearest tooth by
prolongations, of a lejigth proportioned to the extent of the
obturating plate; but we renounced this method, because lig-
atures, ascending incessantly above the neck of the tooth and
the gum, wounded the latter and loosened the former, and
occasioned insupportable pain ; we then had recourse to
crotchets forming springs ; and as the first had a tendency to
slip up upon the teeth, like the ligatures, we soldered to one, and
often to two points of their inferior border, another small
crotchet, a kind of stopping pin, which in bending below rests
upon the crown of the tooth, and prevents the principal
crotchet from slipping as we have already many times said.
As all the teeth do not offer a sufficient surface to hold this
stopping pin, some authors, amongst others Delabarre, and
after him Lefoulon, have advised a groove to be made with a
file on the side of the crown. We, ourselves, think, that
it would be better to solder the crotchet to a small frame en-
veloping the tooth, as we have already shown in several in-
stances ; the teeth, in every case, and particularly in the one
which we are now treating of, are too expensive to have
their solidity compromised by any means whatsoever, and for
a still greater reason by a loss of substance for which there is
no necessity. We have applied many obturators constructed
in this manner, and we have had them commended for their
adjustment and solidity.
If obturators, 7 war^a-jo/acec?, have this great advantage over
obturators m^rof/wce^Z of presenting no obstacle to the occlusion
of the division of the palatine bone, it must also be acknow-
ledged that they neither favor_or aid this occlusion. It might
OR, MECHANICAL DENTISTRY. 531
in the case where the division, resulting from some disease
which affected only one point of the palatine bones, leave
them in relation upon some other points, and thus render it
an absolute impossibility for them to unite except by the meet-
ing of the edges of the opening. But as we have said at the
commencement of this article, the division of the palatine
bones does not always result from an accident which may be
Hmited by perforating them, these bones are very often altogether
separated from each other, and this separation, generally con-
genital, coincides often, we know, with a division either of the
lips, or with the veil of the palate, as in the case of the
patient who became the subject of the interesting discussion
between Blandin, Velpeau and Gerdy, and of which we have
given some of the most important points. It is in this case
that obturators should not be confined to filling the opening,
without placing an obstacle to its occlusion, but they should
directly favor this occlusion. Unfortunately science, it is to
be regretted, has no means capable of filling this last indica-
tion ; for, as Blandin observes, with reason,* "that which op-
poses the success of staphyloraphy in the case of the division
of the palatine, is this division itself and the state of separation
in which the soft parts are held."
"Also," adds this practitioner, "an important service may
be rendered to the unfortunate effects of this defective confor-
mation, by proposing a method which may at an early period
narrow and obliterate the cleft of the palatine vault. We may
thus change a complicated into a case altogether simple, in
which the operation most frequently succeeds. Levret, Jour-
dain and Antenrieth have endeavored to fill this indication ;
Roux has attempted the compression of the dental arches from
without inwardly." To these names Blandin might have
added those of Le Blane,t of (iuesnay,| of Desault,|| and even
of Dupuytren.§
* Dictionary of Medicine and Practical Surgery, vol. xv, p. 17.
t Summary of Surgical Operations ; vol. i, p. 25.
J Journal of Medicine; year 1773, vols, xxxix and xl.
II Surgical Works; vol. ii, p. 205.
§ Oral Lesons, published by Marx and Briere of Boismont.
532 OPERATIVE MEDICINE AND PROSTHESIS,
What methods have these authors employed for exerting
this compression? All which our researches have taught us
in this respect is that Levret and Antenrieth have exerted a
compression upon the lateral parts of the jaw, that Jourdaiu
exerted a double traction in contrary directions upon the two
ranges of molar teeth ; that Roux, after being in conversation
with Miel and making several experiments with him, had en-
trusted to a mechanic whose name he does not mention, the
care of fabricating an apparel appropriated to this usage, but
of which he gives no description.
Finally, Vidal de Cassis* simply expresses himself thus in
this respect : "We may aid nature by a compressive bandage
acting under the two cheek-bones, or by metallic wires traversj
ing the palatine vault, and binding the molares on the oppo-
site side. If these means are well supported, they will abridge
very much the time necessary for its union." That which is
nothing more than the procedure of Jourdain, who wrote when
he was sixty-five years of age, with this difference, however,
to the credit of this master in our art, that he used silk and
not metallic bands, for good reasons which have escaped the
attention of Vidal de Cassis ; "1st, that this wire might injure
the teeth ; 2nd, that if it is fine gold, it will loosen in extend-
ing; 3rdly, this hard body, touching the tongue or rubbing
the gums, might wound them."f
Desirous of responding to this honorable appeal made by
Blandin to our art, we have imagined for this purpose many
apparels free from the hurtful action of all ligatures applied
upon the teeth which they do not fail to loosen. The first is
a band of platina, or of palladium, which is still harder, carry-
ing an obturating plate, then exactly adapted to the palatine
vault in a transvere direction, and proceeding from each side,
bent upon the teeth to a level with the alveolar arches ; but in
such a manner that the descending branches, resulting from
each curve, far from being applied upon the portion of the
palatine vault, and the alveolar border to which they corres-
* Work quoted, vol. iv, p. 195.
t Work quoted, vol. i, p. 451 .
OR MECHANICAL DENTISTRY. 533
»
pond, are separated from them by a distance proportioned to
the widening of the bone which we wish to draw together.
Then, its extremities are pierced by a hole intended to receive
a vice, which, put in rotation, moves before it, or rather from
without inwardly, a plate placed upon this arch, and pressing
upon it to a sufficiently great extent.
This apparel seems to us, at first, to have the inconvenience
of injuring the internal part of the jaws by the inevitable pro-
jection of the vice intended to perform the pressure. We sub-
stitute for it another, which acts, on the contrary, no more
in compressing the dental arches, but in drawing them
together. In order to accomplish this, the apparel was placed
interiorly, and composed of an obturating plate in the mid-
dle of which a clicking pivot was fixed, which, turned by
raeans of a key, would draw to it two pieces proceeding from
each side, to embrace exteriorly the dental arch as the plate
upon which the vice of the first apparel exerted their pressure.
These two apparels, as we see, exerting an eifort, which in-
creases only each time that we make the vice turn a step in the
first, and the pivot in the second, acting by saccades,and not as
it is to be desired in every case where we wish to force an organ
from its place, by a gradual but slow and continued tension.*
From a knowledge of the fact that a division of the palatine
bones which frequently accompanies congenital hare-lip, is ef-
faced by the simple compression, which is then maintained
united, at first by needles, and then by their cicatrization, ex-
ert upon the whole of the anterior part of tlie maxillary, we
seek a method which imitates, as nearly as possible, nature in
this action. The following are the two methods which we
have adopted.
The first consists, simply, in enveloping all the anterior part
of the superior alveolar arch in an elastic steel-band, whos§
two branches, furnished with leather, or, what is still better.
India-rubber, acting by their continued reaction nearly as Du-
puytren represents, who aided the action of the lips by means
* See that which we have said on this subject in our chapter devoted to
dental orthopedy.
62
534 OPERATIVE MEDICINE AND PROSTHESIS,
«
of two compressed cushions against the jaw, maintained by
two metallic springs around the cranium. But the application
is painful, because the difficulty of overcoming its elasticity in
adapting it to the mouth, increasing, of necessity, in propor-
tion as its extremities advance, its progression becomes pain-
ful and even insupportable, before having exactly embraced
the whole of the alveolar border, for which it is designed. It
has, besides, the inconvenience of pressing upon the gums, so
much as to make us fear that mortification may result from it.
We, consequently, seek an easier method, which we will now
describe.
We constructed a palatine obturator, filling exactly the
whole palatine vault, and fixed to the teeth by three crotchets
soldered upon each side so as to encap the canines, the two
small molares, and, also, the two large ones, then bent it upon
the alveolar border, which would protect it from all effort.
This palatine plate being well adjusted, we divide in two from
before backwards, and we remove from it on each side, so that
the edges would remain separated from each other about a fin-
ger's width. We then replace that which we had removed
from the halves of platina by a thick and resisting band of
India rubber, a little smaller than the space which separated
the two halves and to which we solidly rivet it. The apparel,
making as before but a single obturating plate, was no larger,
as we see, than may be necessary for the crotchets to surround
the teeth to which they should be attached.
But by means of two bent bands, proceeding transversely
from one of the derai-plates where they were rivetted to hinge,
' to the other where they were received into a small screw-ring,
the plate would cover the necessary space by the tension of
the India-rubber. The apparel was then placed in the mouth.
Once well adjusted, we make the bands with crotchets leave
their screw-rings, and we remove them by means of a turn-
vice ; the India-rubber, ceasing to be distended, then shrinks
upon itself, and, in this re-action, draws necessarily from with-
out inwardly the alveolar arches by an action altogether simi-
lar to that which the lips, in the healing of their congenital
division, exercise upon the palatine bones against which they
OR MECHANICAL DENTISTRY. 535
had for a long time made a violent pressure. We are as mucii
more induced to believe, from the result of this action, that
Roux* thinks that the union of the veil of the palate, by the
operation of staphyloraphy, might alone affect the drawing to-
gether of these bones.
The principal action of this apparel resides in the tension of
the India-rubber, we might replace the extensive screw-rings,
which never offered a great solidity, at least as the plate was
not forced in the place where they were screwed, we might
replace them, we say, by a metallic band which, a little larger
than the India-rubber one, might be received in the groove
under this latter in order to give to this plate the necessary
size. This plate once placed and properly fixed, we withdraw
the band, which would cause the elastic band to return upon
itself and accomplish the desired end. We might force this
apparel by placing first one of its sides upon the teeth, then
by extending this band to the necessary degree in order to
make it enter the other side. Finally, as the India-rubber
band distended and placed in an atmosphere constantly warm,
might soon lose its elasticity, we would in time be obliged to
replace it by another.
Nevertheless, in a sum total of these different apparels, the
action of the first could be most relied upon, first, because it is
so simple, then, because of its great force. It is, also, the
opinion of professor Lisfranc, to whom we have submitted
them, and who has wished us to promise to give a descrip-
tion of it on the first occasion. However that may be, that
which is of particular importance, is that the action of the in-
strument is felt upon the alveolar border, and not upon the
teeth which loosened, and even completely removed.
Maxillo-palatine Obturators.
In combining that which we have previously said of max-
illary obturators, with what we shall say of palatine obtu-
rators, we may construct the palates or plates of palates
with dentures. We are content to indicate these pieces,
• See page 76 of this Treatise, already quoted. French edition.
536 OPERATIVE MEDICINE AND PROSTHESIS,
leaving to the mind of the dentist the care of conforming
to the mnhipHcity of cases of this nature which may pre-
sent themselves to his observation, and which would each de-
mand a particular description, if we had not under our eyes so
curious an example of it, which we think we should relate.
It is of a young man at present a wine merchant, at Paris,
who, beit)g in a military regiment, then in Africa, had been
taken a prisoner by the Arabs, and had had the whole left
side of the superior jaw fractured by blows from a but-end of
a musket. All the bone, too, to which the large molares were
attached dropped out, carrying with it the superior parts which
prolonged in front under the cheek bone, and that which, in
curving within, formed at the same time the palatine vault
and the floor of the nasal fossae.
The piece that we made for this young man, sustained by
many crotchets, embracing largely the teeth which they sur-
rounded and which some bent pins upon the triturating face
prevented them from injuring the necks, was formed of a sin-
gle metallic plate divided in two parts; one, active, a true ob-
turator, very convex, was applied on the left side upon the
palatine perforation which it hermetically filled, was bent
upon the alveolar border which it exteriorly embraced ; the
other part, jycrsst'ye, or a simple support, covered the posterior
face from all the right dental range, to the molares to which
they were intin)ately united by crotchets.
In the place corresponding to the loss of substance was ap-
plied a piece of hippopotamus upon which the absent teeth
were drawn, furnished with their gums ; this piece was main-
tained by two pegs soldered to the plate and rivetted upon the
triturating face of the teeth. The two parts of this piece was
left free, by the curve which their assemblage offered, an in-
terval large enough, for the sense of taste to be exercised ; an
important precaution which it is always prudent to take in the
adjustment of pieces of this nature.
We might, as we readily perceive, remove from this apparel
the anterior portion of the plate which bends behind the right
teeth, and unite simply its obturating part by a transverse
baud with a frame which might surround the opposite mo-
OR MECHANICAL DENTISTRY. 537
lares ; this would be much easier to execute, but less solid,
because we would necessarily deprive it of the support which
the anterior teeth furnish.
There is still a case which should be mentioned, it is that
where a palatine opening, needing an obturator, is desired by
a person whose superior jaw is completely deprived of teeth.
How can it be maintained in place? This is a question which
would require to be solved all that which we have said of dou-
ble or complete dentures, whose superior portion is main-
tained by springs attached to the inferior. To obturators of
the kind of whicli we are now speaking, two springs should
be fixed, such as we have described, and they should be at-
tached to a band or metallic cap enveloping the posterior teeth
of the inferior jaw, at least if the patient does not prefer a com-
plete superior denture, to which an obturating plate should be
fixed. This denture should always, as far as possible, be
mounted upon a metallic base which harmonizes better, under
all relations with this plate. By one of these methods 6very
rational indication might be filled.
The strange form, which the accidental openings by which
the mouth may communicate with the nasal fossae, may offer;
the various complications which may accompany them, as
disorders following them at the same lime or a distant period
in the dental apparel ; the varied nature of the causes under
the influence of which they are declared, are sufficiently fore-
seen, as the mechanical means appropriated to their occlusion
are those whose construction offers the most difficulties and
requires the most precaution and skill on our part.
Summary of the Principles and Rules ichich should always
serve as a Guide in the Coinhinalion and Adjustment of
Pieces.
Those who intend practising our art, will find, doubtless,
in that which we have said upon dental prosthesis a rule ap-
plicable to the plurality of cases and principles, whose study
would serve as a guide in the course of a career which is most
difficult to fill worthily, which does not seem to be gen-
62*
538 OPERATIVE MEDICINE AND PROSTHESIS,
erally believed, and point out those shoals that experience
alone will, unfortunately, teach them how to avoid.
But they will deceive themselves if they hope to find means
adapted to every case, under all circumstances, because there
are not two patients to be met with in perfectly similar condi-
tions, and that, upon twenty individuals requiring our aid for
the same object, each would demand, perhaps, a modification of
details, or a particular combination, either in size or form,
consequently the dentist is obliged to depend upon his
own judgment and ingenuity.
This would not be the case if all would limit themselves in
this important part of our art, to the pure and simple fabrica-
tion of instruments of prosthesis. With some anatomical
knowledge, however summary, we may always combine
pieces sufficiently well to imitate organs whose result is to re-
place the loss and fulfil the functions of the natural organs ;
for as in sculpturing, we have only to study the forms in order
to copy them. The various difficulties appearing at the
moment when the piece is ready to be put in relation to the
living parts, and consequently irritable, whose sensibility has
to be considered much more, since it is rare that they are free
from diseases, sometimes so serious as to occasion losses
which it is necessary to repair; diseases which are as fre-
quently the result of a constitutional vice as of a local or acci-
dental nature.
A medium intelligence, a glance assuredly, a slight know-
ledge of the means which the imitative arts employ, and
that which we ordinarily term a little taste, will in effect suf-
fice for the fabrication of them ; but the study of the various
points of the sciences of precision, particularly of mechanism,
assisted by physiology, and reduced by practice to fixed prin-
ciples, become necessary to combine the adjustment of pieces
and to maintain them solidly in the place they should occupy.
With ideas furnished by this study, how shall we deter-
mine rigorously the power and manner of using wires, crotch-
ets, sprmgs and other mechanical agents intended to maintain
pieces in this state satisfactorily in an equilibrium which des-
troys the effect of their weight and prevents their traction and
OR MECHANICAL DENTISTRY. 639
rubbing ? how can we arrange these pieces in such a manner
that they will follow the movements sometimes so brisk of the
inferior jaw, without ever abandoning the often irregular
plane which this movable lever offers ; and in such a manner
that they will touch the teeth of the opposite jaw, without oc-
casioning a shock which might loosen their supports and thus
cause them to fall ?
If, however, persons who have resource to our profession
for the replacement of some part of the denture would call
upon us a short time after the loss of this part, we could at
least overcome the difficulties inherent to our art, without
having to combat them that results from the disease which
caused it, and which happen in the majority of cases. But
for the small number sufficiently sensible as not to support the
inconveniences of a difficult mutilation, but easy, however, to
remedy, how many others yield only to the most painful ne-
cessity, and wait, expecting that a long and painful inconveni-
ence, will render them insensible of the loss. Then the ad-
joining parts, having if one is permitted to say so, contracted
new habits, taken new relations, experience when the artifi-
cial teeth are introduced into the mouth at once, a kind of
repugnance, which might result in a brief torture when the
piece was small, but which might even extend to pain when
the piece was large, and for a still greater reason, when it con-
sisted of a whole denture.
Pain is not the only inconvenience that follows this torture,
then, put suddenly in contact with foreign bodies, which press
upon them, inflame, swell, and often become excoriated, and
this purely local pathological condition may give rise to mor-
bid phenomena, very often sufficiently serious to alarm, and,
unfortunately, always sufficiently serious to authorise doubts
upon the forethought of our art, the power of our resources,
and the perfection of our products. How often have we seen
persons complain to us of pieces, besides perfectly made and
properly adjusted, and accuse the dentist of unskilfulness and
ignorance, who had often no other detriment, and which is
sometimes a very great one, then not having warned the pa-
tient of the pain which would undoubtedly follow, or having
promised more than it was possible to obtain.
540 OPERATIVE MEDICINE AM) IMiOsi ii KSIS,
We know, then, that in frequently removing one piece, in
order to immediately replace it, we should have only one end
in view in constructing it, and in condescending to the wishes
of those who wear them, but of gaining time ; for this time en-
genders habit, and habit, it is not necessary to dissimulate, is
to us an important auxiliary. It is even important, in the
most of circumstances, that the work should be so ably com-
bined, that the patient may easily remove it himself, so as to
allow the parts upon which it rests, or which supports its re-
pose, and whose sensibility alters insensibility by' their new
contact; which, however, takes place more certainly and more
quickly, we repeat it, in proportion as the parts are in a better
state of health when the piece is placed.
From thence this double difficulty, which a long experience
and profound study of pathological shading may alone teach
us to avoid ; placing these pieces so soon that the neighbor-
ing organs may not have time to contract new habits, whose
destruction will be always difficult and often painful, and of
deferring their application to so late a period that the diseases
which the loss occasioned, may be entirely cured. Persons
who have recourse to us rarely, unfortunately, determine the
proper period, and address us for reasons of which the health
is far from being the most prominent.
Young practitioners most frequently yield to the sound of
these difficulties which we have mentioned, and from this
precipitation the most serious accidents often result. A fact
related by Taveau* proves this, which he does not fear to give
for this praiseworthy reason, "that science may profit as much
by errors as fortunate cases, and that there is as much merit
in candidly avowing the first as in promulgating the second."
A marine officer presented himself to him in order to have
the six lower anterior teeth replaced, whose fall, according' to
the assertion of the patient, took place without their being
much decayed. Our honorable confrere dfd not find a suffi-
cient contra indication in the swelling of the gums, which he
attributed to the habit the patient had of smoking, made a
* Work quoted, p. 307.
OR MECHANICAL DENTISTRY. ^41
piece, which the first day appeared to be well adjusted, but
it soon rendered the gums so inflamed and painful, that it
could not be supported for at least a month.
This person again calling upon Taveau, he questioned him
more closely than he did at the first interview, and, from the
details in which they entered, he discovered that the teeth
were lost under the influence of a scorbutic affection which
still existed. Taveau advised him then to seek the advice of
a physician and to temporarily remove the piece. This advice
was taken, and, six months after, he with all certainty of suc-
cess, applied another piece, composed then, not of six teeth,
but eight, the two first molares having, in consequence of the
suppuration of the alveoli and other morbid phenomena, which
followed in the course of the treatment, undergone the fate of
the first six.
The dentist should always be ready to know that, if some
persons support with pain, they exaggerate the momentary
torment which is nearly always experienced in the first period
of the application of a piece, and make no effort to overcome
it; others, also, and it is nearly useless to say that these are
particularly women, dissimulate completely this pain by the
desire of experiencing^ no delay and no interruption in the en-
joyment of the advantages which they expect from them.
We saw about three years since, a foreign lady, whose age
and education might have warranted her from a similar fault,
pay for, by the most serious accidents, the obstinate refusal
that she avowed to her dentist, a noble and experienced man,
the pain that she experienced from a pivot intended to solidify
a large piece of denture, but introduced in a root, whose sen-
sibility had not been sufficiently appeased. More recently
still, one of us was obliged to remove for the wife of a farmer
in the department of the Seine and Oise, a piece of denture
which had been placed some days previous, whose pain had
been dissimulated, but which had exerted grievous reactions
and determined serious accidents.
In every case, before commencing a piece, we should care-
fully examine the mouth of the person, and thoroughly notice
the manner in whether it closes and whether the teeth cross or
642 OPERATIVE MEDICINE AND PROSTHESIS,
correspond. We have, sometimes, much trouble to obtain
this result, without which the adjustment of a piece is impos-
sible. Some in the inferior jaw advance or recede, whilst
others cross the superior in front. We have seen some per-
sons among whom this vicious disposition (the inversion) was
natural, seek to correct it by persuading the dentist to take the
impression of some large spaces to fill in their mouths. We
have already observed this fact in treating of dentures or com-
plete pieces.
The foresighi or experience of the dentist should be suffi-
cient to recognise these errors and to arrange all things in the
true relations which should exist between them ; these may
nearly always be accomplished by requesting the patient to
bite naturally, and to apply the teeth squarely and correctly in
the mouth, the only method of judging, with precision and
certainty of its true method of closing.
Notwithstanding all these precautions, a dentist who has
placed a piece of many teeth, often is altogether disappointed
at the result, although he may have previously taken his pre-
cautions and measures, so as to be certain that the closing of
the mouth would be impeded in no way by the teeth of the
artificial piece. In this case, when he k well convinced, after
the remembrance of the inspection and primitive study that
he has made of the mouth of the patient in taking his impres-
sions, that the difficulty in the occlusion of the teeth or the
simple trouble of it was not the fault of the piece, but of an
involuntary contraction, or a spasmodic one of the muscles of
the jaw, he should not trouble himself or take any account of
this new method of closing the mouth, but try the piece again
the next day.
Then he will perceive, with satisfaction, the advantage of
the advice we have given of delay, for the parts having as-
sumed their natural relation, the mouth will close properly, for
the simple reason, that the person, thinking no more of his
piece, will find that the jaw has neither shrunk nor augment-
ed. We have seen some dentists of little capacity, we say it
with regret, shrug their shoulders, in order to make those be-
lieve to whom this has happened, that pieces made by others
OR MECHANICAL DENTISTRY.
543
than themselves, were badly constructed, and that, without
certain dispositions which they would have given, and correc-
tions which they should by all means undergo, they would
never be able to wear them.
We should endeavor not to embarrass our patients, or worry
ourselves, if we would popularise this idea, that it is not use-
ful to expect that a jaw should be deprived of all of its teeth
to be supplied with a large piece of denture, particularly the
superior jaw, because it suffices, sometimes, to include a sin-
gle tooth skilfully in one of these pieces, in order to prevent
it from deviating and from rubbing, which these so often oc-
casion for want of support. The weight of a piece is often
the only method of preserving an isolated one, which having
no support, or exposed to a multitude of efforts, (particularly
on the part of their antagonists,) which they, with difficulty,
resist; which sustained, on the contrary, may last a long time
and render a great service.
We have proofs of this every day. The most recent one
was furnished us by the wife of a distinguished advocate of
the bar of Paris, who, having long since lost the four incisores
and the four small molares of the inferior jaw, had the two
canines entirely isolated, and rendered loose by the continual
shock of their antagonists. Believing that it was impossible
to place a piece without extracting these two teeth, this lady
had supported a long time, with resignation, the precocious
mutilation that her mouth had undergone, when, better in-
formed of the resources of our profession, she applied to us.
We made her a piece, arranged in such a manner that the two
teeth which remained were perfectly enclosed and sustained,
but altogether free from the shock of those of the superior
jaw.
A month had scarcely passed before this piece needed some
slight repairing, and this lady was astonished to find that the
two isolated teeth had not only received no injury from this
piece, but that they had, on the contrary, received great so-
lidity from it. Doubtless, if more teeth were scattered here and
there, the dentist would have more difficulties to overcome;
but this reason, which is only a question of time and labor,
544 OPERATIVE MEDICINE AND PROSTHESIS,
should never frighten the intelligent and honorable dentist-
who should always make it a case of conscience never to
destroy a single tooth in order to simplify a construction or
adjustment of a piece, particularly if this tooth is healthy and
presents no obstacle to the solidity of the piece.
In regard to the complaint that is often made of artificial
teeth because of their disagreeable odor, it is only owing to
the bad adjustment of the piece, and to the neglect of the per-
son who wears them to clean them properly. The dentist
should then establish the most perfect contact between the
piece and the gums or supporting teeth, so as to prevent the
introduction of foreign bodies, principally alimentary particles ;
and this should be accomplished even to the detriment of its
appearance. If he is certain that this contact exists, he should
seek to discover if the change of breath in the person cannot
be ascribed to some other cause, if it does not result, for ex-
ample, from some vice in the digestive or pulmonary organs,
very common among women, and, in general, among the in-
habitants of large cities, particularly in the easy classes.
But, as it is difficult always to obtain an exact contact, and
rare that it can be long maintained, it is prudent for the piece
to be frequently removed by the dentist, particularly if it is of
animal substance, which we are aware is more easily affected
by the buccal fluids. In order to do this, it is useful, even in-
dispensable, to have a piece to change, so that the mouth may
never be unfurnished, and so, that, if one is fatiguing upon
some point, the other would not, probably, be so, and time
might be had to rest this painful point.
It will be very easy, if one desires, to prove to persons who
believe that this recommendation is not for their interest, that
this increased expense is a true economy ; for the piece would
last a much longer time, if it is frequently repaired and pro-
perly cleaned. The manner in which this last direction
should be accomplished, consists simply in rubbing it with a
brush and soap-suds, but, perhaps, better with alcohol mixed
with water, at least if it was not in a very bad state, and con-
siderably aftected with animal odor, which too long a sojourn
in the mouth might cause, and if so, we should have recourse
OR MECHANICAL DENTISTRY. 645
to a very strong aqueous solution of chloruret of chalk. If the
piece was entirely composed of mineral substance, (mineral
teeth and metallic bases,) we should pass it through fire to clean
it. We may, by this means, if it has not been fractured in some
point, return it to its primitive state ; nothing, consequently,
can clean it so perfectly. It is not the same case with pieces,
in the construction of which animal substances enters, par-
ticularly those with bases of hippopotamus : we see them,
in a short time, worn in deep furrows by the buccal fluids,
and become a cause of corruption by the retreat that these
holes ofier for alimentary particles. How can these pieces be
repaired ? Is it necessary, as Delabarre advises, to fill the
holes with a kind of mastic composed of sulphur and sifted
salt? It is easy to see that this kind of bituminous pol-
ishing never gives to the piece a united surface which is
useful, whatever precaution we may take in heating the piece
in order to facilitate the introduction of the cement in all the
anfractures, and leaving no spa:ces.
But it would be better to reduce the depressions to true
holes, and to fill these with pegs of hippopotamus, which we
level with the rest ; or rather to remove the changed parts,
and cover them with a true veneering. But all these repair-
ings constitute defective work ; the dentist should, for the
credit of his profession avoid them as much possible ; better
OFTEN TO REFRAIN THAN TO BADLY ACCOMPLISH, a recom-
mendation that we cannot too often give to our young con-
freres, who should make it a rule, and who should not at least
apply to the primitive construction of a piece the various re-
pairs which it may need.
It may be observed, from that which we have said, we pro-
fess a medium opinion, between Maury on the one hand,* who
thinks that artificial pieces should never be removed, even to
clean them ; and Lefoulonf, who makes an exception of com-
plete dentures ; and on the other of DelabarreJ and Taveau,||
the first of whom believes, that it is advantageous to displace
* Work quoted, p. 328. t Work quoted, p. 352.
X Work quoted, vol. li, p. 469. |1 Work quoted, p. 310.
63
546 OPERATIVE MEDICINE AND PROSTHESIS,
them frequently ; the second, that it is not only useful, but in-
dispejisable to remove them every day.
To the first, we object, because there are certain accidental
positions, whether diseased or not, which, rendering the gums
all at once tumid, as is the case in simple fluxions, and, as we
have frequently seen, for example, among females at menstrual
periods, place their precept often in fault, by imperiously de-
manding the removement of the piece; to the second, we
would remark, that the more we remove a piece, however well
made or properly adjusted, that we loosen the supporting
teeth, and injure the solidify of those which this piece should
support, as we have often seen, and of which we will give ex-
amples at a convenient opportunity.
We conclude, then, that nothing can be absolutely estab-
lished on this subject, and that all principles emitted, a jymri,
that is to say, in the formal designation of the conditions of
their applicatioii, may be contested. Nevertheless, the obliga-
tion one is under of removing, from time to lime, pieces of artifi-
cial denture, comprises, by all means, palatine and maxillo-
palatine obturators, an obligation which had not escaped the
observation of ancient moralists,* and to which the particular
method of attaching and fixing dentures or complete pieces
permits to sacrifice at pleasure, does not apply, we expressly
say it, that those which are attached by pivots, at least if the
roots upon which these pieces are implanted are not changed,
or the substance forming the pivot, or simply its setting, in a
state of decomposition. It is not then, as we see by the ex-
ception, necessary to remove them in order to clean them, but
only when we wish to repair them.
Apart from these two circumstances, which are on the one
hand, the alteration of the supporting root, and on the other
the decomposition of the pivot if it is of wood, or of its setting,
if it is metallic. Pivot teeth which offer the type of solidity,
. . * "JVec denies uliler quam serica, necte,
reponas.'"
"Each evening thou should'st remove thy teeth, as thy robe."
Martial, Lives ix, p. 38.
OR MECHANICAL DENTISTRY. 547
and, particularly, of the simplicity of our means, may last
many years without forming the least disagreeableness, or de-
manding any more care than that which we daily give to the
mouth. We will not return to these different precautions to
which we have given all importance, and devoted one of the
principal chapters of the first part of this work ; the desire
of avoiding repetition, and of saying nothing which is not
absolutely useful and even indispensable, obliges us to close
here.
CONTENTS.
Introduction,
PART FIRST
ANATOMY, ORTHOPEDIA, PATHOLOGY AND THERAPEUTICS.
CHAPTER I.
Anatomy of the Teeth,
Number and Position of the Teeth,
Exterior Conformation of the Teeth, .
The Incisores,
General Character of the Incisores,
Difference in the Characters of Incisores,
Canine, or Laniar Teeth,
General Characters of the Canine Teeth,
Difference in the Characters of the Canines,
The Molar Teeth,
General Characters of the Bicuspides,
Difference in Characters, . -
General Characters of the Large Molar Teeth,
Difference in Characters,
Structure of the Teeth,
Teeth of First Dentition,
Varieties and Anomalies of the Teeth,
Varieties of Teeth according to Ages,
Varieties of Teeth according to Individuals,
Variety in the Form of the Teeth,
Varieties in the Direction of the Teeth,
Varieties of the Position of the Teeth,
Varieties in the Structure of the Teeth, .
The Maxillary Bones and their Alveolar Border,
Summary Anatomy of the Gums,
Nerves and Vessels of the Dental Apparel, .
CHAPTER II.
Physiological History of the Dental Apparatus. De-
velopment OF THE Teeth, or Dentition,
Dental Follicles, . . • •
19
22
23
25
25
26
26
27
^7
28
28
29
29
30
31
39
41
41
42
45
46
46
47
48
54
56
61
61
550 CONTENTS.
FACE.
The Pulp or Dental Papilla, ... 63
Development of the Follicles, . . .64
Development of Dental Bone, . . - 66
Formation of Ivory — Formation of Enamel, . . 68
The Growth and Eruption of the Teeth in General, 71
The Eruption of the Teeth in General, . . 76
Eruption of the Teeth of First Dentition, . . 81
Shedding of the Milk or Temporary Teeth, . . 85
Eruption of the Teeth of Second Dentition, . 87
Phenomena subsequent to the Arrangement of the Teeth, 95
Functional Importance or Uses of the Dental Apparatus,; 97
Articulation of Sounds, .... 100
Secondary Functional Importance, . . 102
SuMMARir AND CONSEQUENCES OF THE PRECEDING PhTSIOLOGI-
CAL Facts, ..... 103
CHAPTER III.
Dental Hygiene and Orthopedia, . . . 112
Sec. I.— Of the Means of Directing the Eruption of the Teeth,
and Facilitating their Arrangement, . . 113
Second Dentition — Indirect Means to Prevent Errors, . 116
Direct Means to Prevent Errors of Second Dentition, 118
Sec. 2.— Of the Different Means of Preserving the Teeth, . 121
General Cares, .... 122
Special Cares, , , , , .125
Elixirs, Powders and Soft Dentifrices, . . 127
Opiates and Mixtures, .... 130
Sec. 3.— Of Tartar, and the Means of Removing it, . 133
Sec. 4.— Of the Means of Remedying Irregularities of Dentition —
Vices of Conformation dependent upon the Teeth, . 138
CHAPTER IV.
Pathology and Therapeutics, . . . 144
Vital or Pathological Changes— Diseases of the Follicles, 144
Congenital Defects of the Enamel, . . .147
Decomposition of Enamel, . . . * 150
Discoloration of Enamel, . . . ' . 151
Consumption of the Roots, . . ' . ' J53
Dental Caries and its Varieties, . . * . 154
Exostosis and Spina- Ventosa, . . . ' 179
Softening of the Teeth, . , . * jsi
Diseases of the Dental Pulp, . ' . * * 182
Nervous or Dental Neuralgia, • " . * . 186
Physical Changes of the Teeth— Wearing Away of the Teeth 191
Cracks and Fractures of the Teeth, . ' 195
Concerning Accidental Luxation of the Teeth, ' ' 200
Ot the Loosening of the Teeth, 202
Diseases OF jhe Dental APPENOAGES-Diseases of the Gunis, 203
Inflammatory Diseases of the Gums, 204
Abscess and Dropsy of the Maxillary Sinus. ' ' 219
Adhesion of the Gums to the Jaws and Lips * 226
Constitutional Affections of the Gums, *^ ' ' '228
CONTENTS. 651
PAGE.
Gangrene and Sphacelus of the Gums, . . 234
Tumors of the Gums, .... 235
Diseases of the Alveoli, . . . .241
PART SECOND.
Operative Medicine and Prosthesis, or Mechanical Dentistry.
CHAPTER I.
Operative Medicine, .... 259
Sec. 1.— Filing of the Teeth, ... 264
Sec. 2.— Cauterization of the Teeth, . . . 273
Sec. 3.— The Obliteration or Plugging of the Teeth, , 279
Sec. 4.— Luxation of the Teeth, .... 288
Sec. 5.— Excision of the Teeth, . ^. . 290
Sec. 6.— Of the Extraction of the Teeth, . . . 293
Of the Instruments generally used for the Extraction of the
Teeth, . . . . .297
Methods Applicable to the Extraction of the Different
Classes of Teeth, .... 317
Extraction of Roots, .... 322
Extraction of Teelh situated out of the Range of the Dental
Arches, and of Concealed Teeth, . . 326
Recapitulation of the Rules applicable to most Cases of
Extraction, ..... 337
Of the Accidents which may Result from the Extraction of
the Teeth, . . . . .342
Partial Fractures of the Maxillary Bones, . 367
Complete Fracture of the Inferior Jaw, . . 372
Luxation of the Inferior Jaw, . . . 377
CHAPTER IL
Prosthesis or Mechanical Dentistry, . . . 380
Of Substances Employed for the Construction of Pieces of
Artificial Teeth, . . . .386
Teelh of the Hippopotamus, . . . 388
Human Teeth, . . . . .395
Mineral Teeth, .... 399
gee. 2. — Of the Metals used in the Dental Prosthesis, . , 425
Manner of taking Impressions, of making- Moulds, of Ad-
justment and Stamping Plates or Bases of the Different
Pieces of Artificial Dentures, . . . 433
Of Impressions or Moulds in Wax, . . 434
Of Models or Moulds in Relief, . . . 437
The Construction of Plates or Cuvettes and Stamping them, 440
Different Methods of Mounting Pieces of Artificial Dentures,
that is to say, of uniting Teelh to their Supports or
Bases, ..... 446
./
552
CONTENTS.
Pivot Mountings, ....
Human Teeth Mounted upon a Pivot,
Mineral Teeth Mounted upon Pivots,
Mounting Teeth upon Plates or Metallic Bases,
Human Teeth Mounted upon Plate,
Mineral Teeth Mounted upon Plate, .
Mounting on Osseous Bases,
Mounting upon Mineral Bases,
Of the Different Methods of Fixing and Maintaining in the Mouth
Pieces of Artificial Denture,
Pivots, or Implanted Tenons,
Pieces held by Simple Co-adaptation,
Of Crotchets, ....
Of Ligatures, . , . . •
Of Springs, . , . , .
Spiral Springs, . . . . •
The Application of all that which precedes, in Regard to the Par-
ticular Construction of Various Kinds of Ordinary
Pieces of Artificial Denture,
Exceptionable Pieces,
Complete Dentures, vulgarly called Rateliers, .
Maxillary Obturators,
Palatine Obturators, . . • •
Maxillopalatine Obturators,
Summary of the Principles and Rules which should always serve
as a Guide in the Combinations and Adjustment of
Pieces, ... . •
PAGE.
448
449
452
454
454
456
458
463
465
466
475
477
485
491
492
502
505
506
518
523
535
537
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